Saint Joseph Hospital

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 43825 Based on the life safety code complaint survey complete on 4/30/2025, the facility failed to comply with regulations set forth in the Life Safety Code. The Condition of Participation §482.41 Physical Environment was out of compliance. A-0700 - The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. The facility failed to comply with the regulations set forth for Life Safety. A deficiency was cited under the Life Safety Code K-0511. See survey event ID 3G6H21 for full details of the cited deficiency.”

“An abbreviated survey, prompted by #CO39732, was completed on 4/30/2025. One deficiency, which presented immediate jeopardy of serious adverse outcomes to building occupants, was cited. Although immediate jeopardy was removed prior to survey exit, deficienct practice with condition-level findings remained for §482.41 PHYSICAL ENVIRONMENT. §482.41 PHYSICAL ENVIRONMENT The Colorado Department of Fire Prevention and Control conducted this survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The Initial comments, (ID Prefix Tag #K000) are informational only and a representation of the facility’s general characteristics. The facility is a three story building CMU wall Type II (000), the FSED is only on the first floor. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 2018 and is licensed for 12 beds. The complaint survey was conducted on April 4th, 2025 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 18, New Health Care Occupancies, “ NFPA 99, Health Care Facilities Code (2012); and all referenced standards. The facility will meet these requirements when the following deficiency is corrected. The deficiency cited was discussed with the Administrator and Maintenance Director during the exit conference conducted at the end of the on-site survey. The Administrator reported the daily census to be one patient on April 30th, 2025”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 43825 Based on observations and staff interview it was determined the facility failed to maintain the protection for the natural gas piping, in accordance NFPA 101. Specifically, 18.5.1.1 9.1.1 Gas equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code, or NFPA 58, Liquefied Petroleum Gas Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. Utilities shall comply with the provisions of Section 9.1. NFPA 54, National Fuel Gas Code, 2012 edition. The deficiency affected two of two smoke compartments. These failures created the likelihood of serious adverse outcomes for all patients, staff, and visitors if any failing exterior cladding were to dislodge then strike the exposed natural gas piping, which located in an area beneath where façade materials had fallen. Findings include: I. Immediate Jeopardy A. Findings of Immediate Jeopardy Regulatory Requirements 7.2 Installation of Piping. 7.2.1 Piping installed aboveground shall be securely supported and located where it will be protected from physical damage. Where passing through an exterior wall, the piping shall also be protected from corrosion by coating or wrapping with an inert material approved for such applications. The piping shall be sealed around its circumference at the point of the exterior penetration to prevent the entry of water, insects, and rodents. Where piping is encased in a protective pipe sleeve, the annular spaces between the gas piping and the sleeve and between the sleeve and the wall opening shall be sealed. Observation and Interview The exterior of the off-campus location building was observed with staff #1. Observation revealed: - The building exterior cladding/façade that consisted of brick, stone veneer, and precast concrete. Precast concrete, brick and stone veneer had fallen from multiple areas of the building façade. Veneer was observed to be missing from both upper and lower floors of the building exterior. - Natural gas pipe ran, exposed and uncovered, along the exterior of the building. Directly above the exposed gas piping, a row of precast concrete was missing. Above the gas piping, there were three additional rows of the precast concrete and approximately nine feet of the brick or stone veneer. Staff #1 confirmed that the falling façade could strike the exposed natural gas piping. Staff #1 acknowledged such a strike could break the exposed natural gas pipe causing a gas leak and/or an explosion. Staff #1 was unable to determine if the missing precast concrete above the gas piping had fallen off or if it was removed for safety reasons. Staff #1 indicated the failing veneer/exterior cladding was a result of installation problems when the building was constructed fewer than 10 years ago. The problems with the exterior façade had only become apparent in recent months, according to staff #1. B. Notification of Immediate Jeopardy Staff #1 was informed of the immediate jeopardy on 4/30/2025 at 11:50 a.m. C. Facility Plan to Remove Immediate Jeopardy The plan to remove immediate jeopardy, provided via email by staff #2, read: “Plan of Correction: Northglenn FSED, 4/30/25, 3:30 pm Noncompliance: The exterior of the building has compromised construction. There is brick falling on all sides of the building. Brick has fallen from the top of the building which is a 3-story building. The natural gas emergency generator piping is not protected from falling construction materials. 1. Galvanized metal coverings will be installed over the horizontal sections of the gas pipe identified. These metal coverings will not touch the pipe and will be secured to the wall/overhangs. 2. This work will be completed no later than 6:00 pm tonight. The supplies have been purchased, and the contractor is onsite and has already begun the work. Serious injury, serious harm: The natural gas piping not being protected from falling debris could cause significant issues in the building, as the emergency generator could not function properly and could cause an explosion that would be very dangerous to the patients and staff. 1. Galvanized metal coverings will be installed over the horizontal sections of the gas pipe identified. These metal coverings will not touch the pipe and will be secured to the wall/overhangs. 2. This work will be completed no later than 6:00 pm tonight. The supplies have been purchased, and the contractor is onsite and has already begun the work. Need for Immediate Action: To ensure that the natural gas piping is protected from falling debris and damage. 1. Galvanized metal coverings will be installed over the horizontal sections of the gas pipe identified. These metal coverings will not touch the pipe and will be secured to the wall/overhangs. 2. This work will be completed no later than 6:00 pm tonight. The supplies have been purchased, and the contractor is onsite and has already begun the work.” Based on the submitted plan, the facility was notified the immediate jeopardy was removed on 4/30/2025 at 4:39 p.m.”

“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: 46674 Based on observation, interviews and document reviews, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements. FINDINGS 1. The facility failed to meet the following requirements under the EMTALA regulations: Tag 2408: §489.24(d)(4),(5)(4) Delay in Examination or Treatment.(i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status.(ii) A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section.(iii) An emergency physician or non-physician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section.(iv) Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. Based on document reviews and interviews, the facility failed to comply with the Emergency Treatment and Labor Act (EMTALA). Specifically, the facility failed to ensure the registration process did not delay examination and treatment in three of four pregnant patients who sought emergency care. (Patient #1, #22, and #23)”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 46674 Based on document reviews and interviews, the facility failed to comply with the Emergency Treatment and Labor Act (EMTALA). Specifically, the facility failed to ensure the registration process did not delay examination and treatment in three of four pregnant patients who sought emergency care. (Patient #1, #22, and #23) Findings include: Facility policy: The Emergency Medical Treatment and Labor Act (EMTALA) policy read, neither the medical screening exam nor any required stabilizing treatment for an emergent medical condition shall be delayed to inquire about the individual’s insurance status. Under no circumstances shall an individual be required to complete a financial responsibility form prior to receiving a medical screening exam and/or necessary stabilizing treatment. Registration could occur so long as it does not delay or otherwise adversely affect the medical screening exam and/or treatment to stabilize an emergent medical condition. 1. The facility failed to ensure the registration process did not delay examination and treatment for pregnant patients who sought emergency care. a. On 12/12/2024 at 7:24 a.m., the financial responsibility form, referred to in the EMTALA policy, was requested. The Agreement for Assignment of Insurance Benefits consent was provided. Review of the Agreement for Assignment of Insurance Benefits consent revealed section one allowed the facility to bill and receive payment from patients’ insurance companies. Section two was a statement of financial responsibility in which patients promised to pay for any service not covered by their insurance company. b. Medical record review revealed Patient #1, who was 39 weeks and 6 days pregnant, arrived at the facility on 12/2/24 at 6:36 a.m. with a chief complaint of contractions. Patient #1 signed the Agreement for Assignment of Insurance Benefits consent (financial responsibility form) at 6:38 a.m. Nursing documentation revealed Patient #1’s vital signs were obtained at 6:45 a.m. and a triage assessment was completed at 6:51 a.m. Provider documentation at 8:11 a.m. revealed Patient #1 was in labor. c. Medical record review revealed Patient #22, who was 36 weeks pregnant, arrived at the facility on 9/8/24 at 11:40 a.m. with a chief complaint of decreased fetal movement. Patient #22 signed the Agreement for Assignment of Insurance Benefits consent at 11:41 a.m. Nursing documentation at 12:27 p.m. revealed Patient #22 reported they did not feel any fetal movement for two days and there were no fetal heart tones. Provider documentation at 12:30 p.m. revealed Patient #22 had an intrauterine fetal demise (death of a fetus). d. Medical record review revealed Patient #23, who was 39 weeks and 1 day pregnant, arrived at the facility on 9/15/24 at 7:49 p.m. with a chief complaint of labor. Patient #23 signed the Agreement for Assignment of Insurance Benefits consent at 7:50 p.m. Nursing documentation at 7:52 p.m. revealed Patient #23 was in 10 out of 10 pain. Patient #23’s vital signs were obtained at 8:00 p.m. and a triage assessment was completed at 8:39 p.m. Provider documentation at 10:16 p.m. revealed Patient #23 had an intrauterine fetal demise. These medical record reviews were in contrast to the EMTALA policy which read, under no circumstances shall an individual be required to complete a financial responsibility form prior to receiving a medical screening exam and/or necessary stabilizing treatment. e. Review of the Admission, Discharge, and Transfer of Emergency Department (ED) Patients policy revealed financial information for ED patients was requested after the medical screening exam had begun. Registration associates could request information from patients to begin the registration process, provided care was not delayed due to inquiry about the patient’s insurance status. f. On 12/12/24 at 8:42 a.m., upon request, the facility was unable to provide a policy or process staff were to follow for how to register pregnant patients who presented to the obstetrics (OB) registration desk for emergency care. g. On 12/9/24 at 10:25 a.m. through 12/12/24 at 8:32 a.m., interviews were conducted with patient access representative (PAR) #1. PAR #1 stated they registered patients in the ED and at the OB registration desk. PAR #1 stated when patients presented to the ED for emergency care, they were asked for their photo ID, the last four digits of their social security number if they did not have a photo ID, their chief complaint, and were provided an identification wristband. PAR #1 stated PAR staff verified patients’ demographic information, collected insurance information, and had patients sign their consents once they had been examined in the ED. PAR #1 stated insurance information was collected after patients had been examined because of EMTALA, and patients were treated whether or not they had insurance. PAR #1 also stated patients were sent from the ED registration desk to the OB registration desk if they were greater than 20 weeks pregnant and had an OB related chief complaint. PAR #1 stated if patients had not preregistered, they were asked to verify their name, date of birth, and provide a photo ID or the last four digits of their social security number. PAR #1 stated they were also asked if they had insurance, or insurance information would be verified with them, and their insurance card would be scanned if it was not in the electronic medical record (EMR) system. PAR #1 stated they were additionally asked how many weeks pregnant they were, what clinic they used, if they wanted a religious visit, and if they wanted their primary care physician to be notified of why they had come to the facility. PAR #1 stated patients then signed their consents and were provided an identification wristband. PAR #1 also stated patients were asked to fill out an OB triage notes paper to give to their triage nurse (including the patient’s name, last four of their social security number, what clinic they used, allergies, current height and weight, due date, how many times they had been pregnant, how many living children they had, and current medications). Additionally, PAR #1 stated when patients presented to the OB registration desk with abdominal pain, were in active labor, or screaming in pain, PAR staff only collected their name, date of birth, and what clinic they used to assign the appropriate provider. PAR #1 stated PAR staff then collected consents and verified patients’ information once they had been stabilized. PAR #1 stated a pregnant patient who presented for lack of fetal movement took priority over a patient who presented for a lactation appointment, but they were registered the same way. PAR #1 stated they did not know why additional information was collected before OB patients were examined versus the limited information collected before ED patients were examined. PAR #1 stated this was the process they were trained to follow. PAR #1 stated labor was pretty much the only medical emergency patients presented to the OB registration desk with. PAR #1 stated they did not want to delay care for patients who were in labor. PAR #1 stated laboring patients needed to be examined and receive the treatment they required. This interview was in contrast to the EMTALA policy which read, neither the medical screening exam nor any required stabilizing treatment for an emergent medical condition shall be delayed to inquire about the individual’s insurance status. Under no circumstances shall an individual be required to complete a financial responsibility form prior to receiving a medical screening exam and/or necessary stabilizing treatment. Registration could occur so long as it did not delay or otherwise adversely affect the medical screening exam and/or treatment to stabilize an emergent medical condition. h. On 12/12/24 at 11:10 a.m., an interview was conducted with OB registered nurse (RN) #2. RN #2 stated there were emergent medical conditions (EMC) that could occur in patients who were greater than 20 weeks pregnant, such as vaginal bleeding, high blood pressure, rupture of membranes, fever, labor, and decreased fetal movement. RN #2 stated nurses and providers determined if pregnant patients had an EMC. RN #2 stated all complaints were treated as urgent. RN #2 stated everyone who presented had an EMC until it was determined otherwise and pregnant patients needed to be assessed to determine what had happened so interventions could be provided. i. On 12/12/24 at 1:13 p.m., an interview was conducted with OB provider (Provider) #3. Provider #3 stated labor, severe preeclampsia (blood pressure condition occurring during pregnancy), abruption (when the placenta pulls away from the uterus), and fetal low heart rate were examples of EMCs patients greater than 20 weeks could experience. Provider #3 stated it was important not to delay the medical screening exam for these patients because staff could not determine these EMCs had occurred unless the patients were talked to and examined by a nurse and/or provider. Provider #3 said patients could be very sick and look well. Provider #3 stated these patients could get sick quickly if the medical screening exam was delayed and their EMC was not addressed immediately. j. On 12/12/24 at 11:46 a.m., an interview was conducted with patient access manager (Manager) #4. Manager #4 stated when unscheduled OB patients presented to the OB registration desk, they should have only been asked for their name, date of birth, photo ID or last four digits of their social security number, chief complaint, and what clinic the patient used to assign a provider. Manager #4 stated PAR staff should never discuss finances unless patients were scheduled visits. This was in contrast to the interview with PAR #1 who stated patients who were not preregistered were asked for their insurance information unless they presented with abdominal pain, were in active labor, or screaming in pain. Manager #4 stated staff completed extensive training to ensure they were fully competent before they were allowed to work the OB registration desk. Manager #4 also stated the facility did not have a policy for PAR staff to follow when unscheduled OB patients were registered. Manager #4 stated if patients appeared to be in distress, had contractions, or were in labor, the Agreement for Assignment of Insurance Benefits consent should have been signed after they had received the medical screening exam. Manager #4 stated they noticed the Agreement for Assignment of Insurance Benefits consents were signed by Patients #1, #22, and #23 when they were registered. This was in contrast to the EMTALA policy which read, under no circumstances shall an individual be required to complete a financial responsibility form prior to receiving a medical screening exam and/or necessary stabilizing treatment. Manager #4 also stated contractions, labor, decreased fetal movement, and anything heart related were key words PAR staff listened for that indicated patients were in distress. Manager #4 stated insurance verification happened after the medical screening examination had occurred for patients who came in with decreased fetal movement, contractions, or in labor. This was in contrast to the interview with PAR #1 who stated insurance information was verified and insurance cards were scanned into the EMR for patients who were not preregistered. This was also in contrast to the interview with RN #2 who stated nurses and providers determined if pregnant patients had an EMC, all complaints were treated as urgent, and everyone who presented had an EMC until it was determined otherwise. Additionally, this was in contrast to the interview with Provider #3 who stated pregnant patients could be very sick and look well, and staff could not determine if pregnant patients experienced an EMC unless the patients were talked to and examined. Furthermore, this was in contrast to the EMTALA policy which read, neither the medical screening exam nor any required stabilizing treatment for an emergent medical condition shall be delayed to inquire about the individual’s insurance status. Registration could occur so long as it did not delay or otherwise adversely affect the medical screening exam and/or treatment to stabilize an emergent medical condition. Furthermore, Manager #4 stated it was important not to delay care because PAR staff were not clinically trained and the patients’ care teams determined their acuity of care.”