Veterans Memorial Hospital

“Roles Under a Waiver Declared by Secretary CFR(s): §403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7). [(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:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. This Standard is not met as evidenced by: 34815 Based on record review and interview, the facility failed to provide a policy for an 1135 waiver in accordance with the Code of Federal Regulations (CFR) at §485.625(b)(8). This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 5. Findings include: Record review and interview on 10/29/24 at 10:20 a.m., revealed the facility was unable to provide a written policy in its Emergency Preparedness Plan to address the role of the facility under an 1135 waiver in the provision of care and treatment at an alternate care site identified by emergency management officials. The CFO verified this observation at the time of the survey process.”

“42 CFR 485.623(d) Veterans Memorial Hospital was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 485.623(d), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 Edition. Veterans Memorial Hospital is a two (2) story building that was built in 1949 with additions in 1976 and 2000. The building is composed of Type II (111) construction. The facility is fully sprinklered and there is supervised smoke detection located in the corridors, resident rooms, and the spaces open to the corridors. The facility has 25 certified beds. At the time of the survey, the census was 5. The requirement at 42 CFR 485.623(d) is NOT MET as evidenced by:”

“Multiple Occupancies - Construction Type CFR(s): NFPA 101 Multiple Occupancies - Construction Type Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows: * The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1 * The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters. 18.1.3.5, 19.1.3.5, 8.2.1.3 This Standard is not met as evidenced by: 34815 Based on observation and interview, the facility failed to maintain a 2-hour fire separation in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.1.3.5), 2012 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 5. Findings include: Observation and interview on 10/29/24 at 12:08 p.m., revealed a 2-hour fire separation with a 3/4-inch and a 1-inch open to the center conduit penetrations being used for communications wiring. Located above ceiling near the PT Entrance in the separation between the hospital and the attached VMH Clinic. The Facilities Director verified this observation at the time of the survey process.”

“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: 34815 Based on observation and interview, the facility failed to ensure that required self-closing doors are maintained in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.2.2.2.7), 2012 Edition. This deficient practice affects approximately 8 residents, staff, and visitors in 2 of 9 smoke zones. This facility has a capacity of 25 and a census of 5. Findings include: Observation and interview on 10/29/24 at 12:10 p.m., revealed the 1-1/2 hour fire rated cross corridor double doors located in the Center Hall near Admitting failed to fully self-close and positively latch within the door frame as required. The Facilities Director verified this observation at the time of the survey process.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 34815 Based on observation and interview, the facility failed to provide separation of hazardous areas in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.2.1.3), 2012 Edition. This deficient practice affects approximately 5 staff in 1 of 8 smoke zones. This facility has a capacity of 25 and a census of 5. Findings include: Observation and interview on 10/29/24 at 12:26 p.m., revealed the corridor door to the 2nd Floor Medical Records Storage Room failed to fully self-close and positively latch within the door frame as required. This room was greater than 50 square feet and being used for the storage of combustible materials. The Facilities Director verified this observation at the time of the survey process.”

“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: 34815 Based on observation, interview, and record review, the facility failed to maintain their fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.6.1.3), 2012 Edition, National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (Section-14.2.1.2.2), 2010 Edition, and National Fire Protection Association (NFPA) 80, Standard for Fire Doors and Other Opening Protectives (Section-19.4.1.1 and Section 19.4.9), 2010 Edition. These deficient practices affect all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 5. Findings include: 1. Observation and interview on 10/29/24 at 9:30 a.m., revealed the fire alarm system control panel (FACP) indicated the system was in trouble mode. 2. Record review and interview on 10/29/24 at 11:19 a.m., revealed the facility was unable to provide any documentation for 6-year inspection and testing of their installed fire and smoke dampers throughout the facility. The Facilities Director verified these observations at the time of the survey process.”

“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: 34815 Based on observation and interview, the facility failed to maintain electrical junction boxes in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.1.2), 2012 Edition and National Fire Protection Association (NFPA) 70, National Electrical Code (Section-314.25) , 2011 Edition. This deficient practice affects approximately 1 staff in 1 of 8 smoke zones. This facility has a capacity of 25 and a census of 5. Findings include: Observation and interview on 10/29/24 at 11:47 a.m., revealed an open electrical junction box with exposed wires located along the east wall in the 1st Floor IT Storage Closet. The Facilities Director verified this observation at the time of the survey process.”

“Evacuation and Relocation Plan CFR(s): NFPA 101 Evacuation and Relocation Plan There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2. 18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3 This Standard is not met as evidenced by: 34815 Based on record review and interview, the facility failed to provide a complete fire safety plan in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.7.2.2(9)), 2012 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 5. Findings include: Record review and interview on 10/29/24 at 11:29 a.m., revealed the provided Fire Safety Plan did not address the use of the different types of portable fire extinguishers in the facility. Nor did the plan address the use of the kitchen hood suppression system. The Facilities Director verified this observation at the time of the survey process.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 34815 Based on record review and interview, the facility failed to inspect and test fire door assemblies in accordance with National Fire Protection Association (NFPA) 80, Standard for Fire Doors and Other Opening Protectives (Section-5.2.1 and Section-5.2.14.3), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 5. Findings include: Record review and interview on 10/29/24 at 11:15 a.m., revealed the facility was unable to provide current documentation for annual inspection and testing for any of the required fire rated door assemblies throughout the facility. To include the rated roll down fire doors located at X-Ray and the Kitchen. Documentation provided indicates inspection and testing was last conducted in 2019. The Facilities Director verified this observation at the time of the survey process.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 34815 Based on record review and interview, the facility failed to inspect their emergency generator in accordance with National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems (Section-8.4.1), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 5. Findings include: Record review and interview on 10/29/24 at 10:43 a.m., revealed the facility is not consistently conducting weekly inspections of their diesel powered emergency generator. Review of their generator logs showed gaps in dates between 08/28/24-09/09/24, 09/26/24-10/07/24, and 10/12/24-10/21/24. The Facilities Director verified this observation at the time of the survey process.”

“CLINICAL RECORDS CFR(s): §485.638 Condition of Participation: Clinical Records This Condition is not met as evidenced by: 48530 This CONDITION is not met as evidenced by: Based on observation, hospital policy review and staff interviews, the critical access hospital (CAH) failed to ensure hospital staff safeguard the confidentiality of patient medical record information through the following: 1) unsecured patient medical record information in open shred bins in the Medical/Surgical Department nurse’ss station and Laboratory Department. 2) unsecured patient medical record information in a Pathology/Send-out testing log binder on the countertop in the Laboratory Department. The cumulative effect of these processes resulted in the potential for patient Protected Health Information to be available for unauthorized access/use of the information at multiple locations in the hospital, affecting patients receiving both inpatient and outpatient hospital services (see C1120).”

“PROTECTION OF RECORD INFORMATION CFR(s): The CAH maintains the confidentially of record information and provides safeguards against loss, destruction, or unauthorized use. This Standard is not met as evidenced by: 48530 Based on observation, hospital policy review and staff interviews, the critical access hospital (CAH) failed to ensure hospital staff safeguard the confidentiality of patient medical record information against the potential of unauthorized access/ use of the information through unsecured patient medical record information in open shred bins in the Medical/Surgical Department nurse’s station and Laboratory Department, along with a Pathology/Send-out testing log binder on the countertop in the Laboratory Department. The CAH reports an average daily census of 5 patients seen per day in the Medical/Surgical Department. Failure to ensure CAH staff safeguard the confidentiality of patient medical record information against the potential of unauthorized access/use placed patients at risk for loss of privacy and theft of their protected health information. Findings include: 1. Review of the hospital ’ s policy, titled Destruction/Disposal of Patient Health Information, dated 5/2024, revealed the purpose of the policy was to establish guidelines for the appropriate destruction of a variety of media that may contain protected patient health information. The policy directed staff to place patient information in a separate wastebasket that was marked and shredded. 2. On 10/22/24 at 8:15 AM, observation during a tour of the Medical/Surgical Department with the Medical/Surgical Manager revealed the Medical Surgical Department was located on the first floor of the hospital. Observation of the Medical Surgical nurse’s station revealed two unsecured open wastebaskets with a paper taped on the front of each instructing staff to place any documents with patient information in it. The wastebaskets were over half-filled with patient identifiable information. The nurse’s station was a large open area with no doors. During an interview 10/22/24 at the time of the tour, the Medical/Surgical Manager explained staff were instructed to place all papers with patient information in the wastebaskets and the information was gathered at the end of the day and taken to a locked shred bin in the basement until the contracted shredding company came to remove it. The Medical/Surgical Manager reported housekeeping came into the area throughout the day to clean and confirmed the unsecured shred wastebaskets had potential for unauthorized persons to gain access to the patient healthcare information. The Medical/Surgical Manager confirmed there were times that staff left the nurse’s station unoccupied. 3. On 10/21/24 at 1:18 PM, observation during a tour of the Laboratory Department with the Laboratory Manager revealed the Laboratory Department was located on the first floor of the hospital. The surveyor observed a Pathology/Send-out testing log binder on the countertop that contained 65 names of patients identifying specimens that were sent for pathology or send out blood tests. Observation in the Laboratory Department revealed three unsecured open wastebaskets with a paper taped on the front of each instructing staff to place any documents with patient information in it, one located under the Laboratory Registration desk and two located in the Laboratory Technician work area. Observation revealed two doors with key lock access to the Laboratory Department. During an interview 10/21/24 at the time of the tour, the Laboratory Manager confirmed the binder with patient health information was left on the countertop at all times. The Laboratory Manager explained staff were instructed to place all papers with patient information in the wastebaskets, the information was gathered at the end of the day, and taken to a locked shred bin in the basement until the contracted shredding company came to remove it. The Laboratory Manager reported the Laboratory Department was not staffed after 4:00 PM to 7:00 AM every night. Housekeeping and Maintenance staff had keys to access the doors (staff that would not have a need to access/know HIPPA protected information).”