Mercyone Oelwein Medical Center

“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 §482.15(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 6. Findings include: Record review and interview on 04/10/24 at 11:26 a.m., revealed that 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 Plant Operations Lead verified this observation at the time of the survey process.”

“42 CFR 485.623(d) MercyOne Oelwein Medical Center 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. MercyOne Oelwein Medical Center is a four (4) story building that was built in 1991. The building is composed of Type I (442) construction. The facility is fully sprinklered and there is supervised smoke detection located in the corridors and the spaces open to the corridors. The facility has 25 certified beds. At the time of the survey, the census was 6. The requirement at 42 CFR 485.623(d) is NOT MET as evidenced by:”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 34815 Based on observation and interview, the facility failed to provide emergency task illumination in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-6.4.2.2.4.2 (3) (b)), 2012 Edition and National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.9.2.7), 2012 Edition. This deficient practice affects all patients who receive medication. This facility has a capacity of 25 and a census of 6. Findings include: Observation and interview on 04/10/24 at 12:32 p.m., revealed the 2nd Floor Medication Room did not contain automatic emergency task illumination. The lights in this room were controlled by a switch. In the event of a power outage this room could be left in darkness if the switch were in the off position even if the facility was under emergency generator power. The Plant Operations Lead 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. These deficient practices affect approximately 15 residents, staff, and visitors in 3 of 11 smoke zones. This facility has a capacity of 25 and a census of 6. Findings include: 1. Observation and interview on 04/10/24 at 12:22 p.m., revealed that none of the 9 corridor doors for the decommissioned nursing facility resident rooms located in the East Wing of the 3rd Floor contained self-closing devices. These rooms were each greater than 50 square feet and being used for the storage of combustible materials. 2. Observation and interview on 04/10/24 at 12:38 p.m., revealed the corridor door to Room #211 on the 2nd Floor did not contain a self-closing device. This room was greater than 50 square feet and being used for the storage of combustible materials. 3. Observation and interview on 04/10/24 at 1:07 p.m., revealed the self-closing device for the corridor door to the ER Clean Supply Storage Room had been disconnected. This room was greater than 50 square feet and being used for the storage of combustible materials. The Plant Operations Lead verified these observations at the time of the survey process.”

“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: 34815 Based on record review and interview, the facility failed to maintain their kitchen hood extinguishment system in accordance with National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (Section-11.2.3), 2011 Edition. This deficient practice could affect all residents, staff, and visitors throughout the facility. Findings include: Record review and interview on 04/10/24 at 12:43 p.m., revealed the agent holding tank for the kitchen Ansul Extinguishment System was past due for 6-year hydrostatic testing. Documentation provided indicates the tank was last tested in December of 2015. The Plant Operations Lead verified this observation at the time of the survey process.”

“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: 34815 Based on observation and interview, the facility failed to maintain sprinklers in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protections Systems (Section-5.2.1.1.2(2)), 2011 Edition. This deficient practice could affect all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 6. Findings include: Observation and interview on 04/10/24 at 12:11 p.m., revealed the fusible link sprinkler located in the 4th Floor Dirty Utility Chute contained excessive green corrosion on the sprinkler arms, diffuser, and fusible link which requires the sprinkler to be replaced. The Plant Operations Lead verified this observation at the time of the survey process.”

“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: 34815 Based on observation and interview, the facility failed to ensure that corridor doors have a means of keeping the doors closed within the door frame in order to resist the passage of smoke in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.6.3.5), 2012 Edition. This deficient practice affects approximately 6 staff and visitors in 1 of 11 smoke zones. This facility has a capacity of 25 and a census of 6. Findings include: Observation and interview on 04/10/24 at 1:00 p.m., revealed the corridor door to the Lab located on the 1st Floor failed to positively latch within the door frame in order to keep the door closed. This was due to the door not containing any latching hardware. The Plant Operations Lead verified this observation at the time of the survey process.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 34815 Based on record review and interview, the facility is not conducting coded fire drills within the allowed timeframe in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.7.1.7), 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 6. Findings include: Record review and interview on 04/10/24 at 10:13 a.m., revealed the 2nd shift fire drill for the 1st quarter of 2024 was a coded/silent drill that was conducted at 7:45 p.m. The timeframe for coded/silent drills is from 9:00 p.m.-6:00 a.m. The Plant Operations Lead 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 maintain their emergency generators in accordance with National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems (Section-8.3.8), 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 6. Findings include: Record review and interview on 04/10/24 at 1:19 p.m., revealed the facility’s alternate backup power was produced by two separate diesel powered emergency generators. The facility was not able to provide documentation for the annual testing of fuel for either of the generators. The Plant Operations Lead 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: 33874 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 shred bins in the Emergency Department (ED), inpatient/outpatient registration area and Medical/Surgical Deparment; 2) unsecured faxed patient medical record information in the RehabilitationTherapy Department; and, 3) unsecured posted listing of patient names (both inpatients and outpatients) along with their scheduled laboratory testing information in the Laboratory Department. The culmulative 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: 33874 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 shred bins in the Emergency Department (ED), inpatient/outpatient registration area and Medical/Surgical Deparment, unsecured faxed patient medical record information in the Rehabilitation Therapy Department and the listing of patient names (both inpatients and outpatients) along with their scheduled laboratory testing information in the Laboratory Department. The CAH reported an average census total of 320 patients per month in the ED, an average of 1300 laboratory tests per month, an average of 80-100 outpatient therapy patients per month and a daily average census of 4 patients per day in the Medical/Surgical Department. Failure to ensure CAH staff safeguarded 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: Review of the hospital’s policy, titled Securing and Safeguarding of Health Information Management, dated 6/23/23, revealed the purpose of the policy was to provide direction and guidelines for the security and safeguarding of health and hospital information against loss, destruction, tampering and unauthorized access and uses. The policy directed staff to strive to ensure that medical records and other information medium were maintained in secure and restricted areas with access limited to those staff members who have a “need to access” based on either patient care needs and/or position responsibilities. 1. On 3/26/24 at 8:04 AM, observation during a tour of the Medical-Surgical Department with the Medical Surgical Nursing Supervisor and Administrator revealed the Medical Surgical Department was located on the second floor of the hospital. Observation of Room 212, identified by the Medical Surgical Nursing Supervisor as one of two physician sleeping rooms revealed a partially open door with the room light off. Upon entering the room, the surveyor observed patient Protected Health Information (PHI) located face up on the top of a filing cabinet and no persons present in the room. On 3/26/24 at 09:10 AM, observation revealed a shred bin that contained unsecured Protected Health Information (PHI) alongside the wall of the Medical-Surgical Department nurse’s station. The Surveyor noted that the door to the shred bin was partially open and, upon further inspection, observed the bin was approximately half-full of unshredded patient medical records. 2. On 3/26/24 at approximately 11:30 AM, observation, during a tour of the Laboratory Department with the Staff V, Laboratory Leader, revealed two large television monitors that displayed the first and last names of 12 patients, a combination of inpatients and outpatients, with their scheduled lab tests to be drawn. During an interview on 3/26/24, at the time of the tour, Staff V, Laboratory Leader, introduced the surveyors to a laboratory equipment technician who was present in the lab at the time of the tour. The laboratory equipment technician was not an employee of the hospital and would have no reason to have access to patient PHI. Staff V, Laboratory Leader, revealed staff never turned off the television monitors and they kept the door to the laboratory unlocked at all times. Staff V, Laboratory Leader, confirmed that housekeeping and maintenance had access to the area and were able to view the information displayed on the monitors. 3. On 3/26/24 at 2:28 PM, the surveyor entered the hospital’s Health Information Management (HIM) Department, which was located on the first floor of the hospital, with the hospital Administrator. Observation of the room revealed 2 entry doors, one door had a lock with a keypad code entry, and the other entry door had a lock with a key entry. The room had a wall with multiple slots. Each of the slots contained documents with patient health information protected with a cover sheet over the patient’s information. The surveyor observed one person in the room, Staff M, Quality Control Index Technician. In an interview, during the same observation, Staff M, Quality Control Index Technician (QCIT), reported the HIM Department had a shred bin with patient medical information that stayed in the department until the contracted shredding company came to remove it. The Administrator reported there were several shred bins located throughout the hospital. 4. On 3/26/24, starting at 2:42 PM, tour of the hospital with the Administrator for the purpose of locating the shred bins throughout the hospital revealed the following: a. Observation of the hospital’s Emergency Department (ED) revealed an unlocked shred bin with a lid located behind the nurses’ station and filled more than halfway with unshredded PHI. The nurses’ station was open on either side with no physical restrictions to access the area behind the nurses’ station. The ED staff included Staff N, RN, Staff O, RN and Staff P, Physician. In an interview, during the same ED observation, Staff O, RN, reported the lock on the bin had recently broken and hospital staff had not replaced it yet. Staff N, RN, did not think that patients or visits would have access to the unlocked shred bin. Staff P, Physician, reported the potential existed for no staff to be present in or around the nurses’ station area in the event a patient coded (the type of emergency treatment a person would receive if their heart or breathing would stop) and all staff responded. b. Observation of the hospital’s registration area for all patients seeking outpatient and ED services revealed the area to be located directly inside of the main hospital entrance and to consist of two offices enclosed by glass. A staff person was seated in one of the offices talking with a patient. Observation of the second office revealed the light to be on, the door partially shut and no one present. Upon entering the office, the surveyor noted an open trash can located under the desk in the room and half-filled with unshredded PHI. The two registration offices were separated by a glass door that was open at the time of the observation. In an interview, during the same observation of the hospital’s registration area, when asked if there was a potential for someone to access the patient healthcare information in the open trash can, the Administrator confirmed this was a possibility. The Administrator reported the registration staff worked 7:00 AM to 5:00 PM, and they locked the offices outside of those hours. Registration staff would leave the registration office area to take patient’s to the ED or laboratory at times. The Administrator explained there were several cameras monitoring the registration area and offices, and they would catch someone if they took the information. c. Observation of the Medical/Surgical Department revealed an unlocked shred bin located behind the open nurses’ station. The shred bin had a lock on it, but the lock was not engaged. The shred bin was more than half filled with unshredded PHI. The shred bin included a sign located on the front of the bin which directed staff to please lock the bin after emptying the bin. In an interview, during the same observation of the Medical/Surgical Department, Staff K, RN, reported they had been told by other nursing staff that there was something wrong with the lock on the bin and to use a pair of scissors to move the lock between the open and closed position. Staff K, RN, demonstrated how to move the lock to the open or locked position with the use of a pair of scissors. Staff K, reported the key for the shred bin was missing. Staff K, RN, reported there were times that the nurses’ station would be left unoccupied while the staff present were working with patients and there was a potential for unauthorized persons to gain access to the patient healthcare information. d. Observation of the Rehabilitation Therapy Department (physical, occupational and speech therapy) revealed the area to be wide open with a large desk/reception area, waiting area off to the side and unrestricted access via the elevator or stairs. The large desk included a fax machine with several documents which contained patient identifiable healthcare information sitting on the print tray of the fax machine. One staff person was present, Staff Q, Physical Therapy Assistant (PTA). The surveyor did not observe a shred bin for the area. In an interview, during the same observation of the Rehabilitation Therapy Department, Staff Q, PTA, reported staff worked in the Rehabilitation Therapy Department 8:00 AM to 4:30 PM, and sometimes, an occupational therapist would come in before 8:00 AM. Staff Q, PTA, reported this was just the fourth time Staff Q had worked at this hospital. Staff Q, PTA, reported she was the only staff person currently in the area. Staff Q, PTA, explained the faxed information was already present in the print tray when Staff Q arrived. Staff Q, PTA, explained that when she came into the department to work, she did not touch the faxes and left them on the machine. Staff Q, PTA, reported they scheduled patients at 40 minute intervals and there was a potential for patients or other persons to be in the area with no one present at the reception desk. Staff Q, PTA, reported the fax machine would just print the information as the information came in. The Administrator reported housekeeping came in to clean the area mid-afternoon daily. 5. On 3/27/24 at 10:55 AM, during an interview, the Medical Surgical Nursing Supervisor reported the lock on the shred bin located in the Medical/Surgical Department containing patient PHI was not broken and they did have a key for the lock on the bin. The Medical/Surgical Nursing Supervisor did not know why Staff K, RN, reported the need to use scissors to unlock the shred bin, or why Staff K, RN, thought the lock was broken. The Medical/Surgical Nursing Supervisor reported the guy collecting the information for shredding had just recently been there, but was usually good about relocking the shred bin after emptying the bin. Observation of the shred bin located behind the nurses’ station against the back wall in the Medical/Surgical Department revealed the shred bin to be locked. The Medical/Surgical Nursing Supervisor reached into an unlocked drawer located in the nurses’ station, pulled a key and demonstrated how the key unlocked and locked the bin.”