North Adams Regional Hospital Corporation

“FREEDOM FROM ABUSE, NEGLECT & EXPLOITATION CFR(s): Freedom from abuse, neglect and exploitation (§483.12(a)(1), (a)(2), (a)(3)(i), (a)(3)(ii), (a)(4), (b)(1), (b)(2), (c)(1), (c)(2), (c)(3), and (c)(4) of this chapter). “ §483.12(a)(1) Freedom from abuse, neglect, and exploitation. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms.(a) The facility must-(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; “ §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. “ §483.12(a)(3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. “ §483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. “ §483.12(b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, “ §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This Standard is not met as evidenced by: 30889 Based on employee record review, policy review and interview, the Critical Access Hospital (CAH) failed to ensure Nurse Aide Registry checks were completed for 4 employees ( #1, #2, #3 and #4), out of a total of 6 employees records reviewed. Findings included: Review of the CAH’s policy entitled, Background Checks, undated, included the following: *Background checks will be conducted on all new hires, re-hires and volunteers. *Background checks may include Nurse Aide Registry. Review of employee records #1, #2, #3 and #4, indicated the following: *The employees were hired for employment at the CAH on 3/28/24, however Nurse Aide Registry checks were not completed as required, for these 4 employees. During an interview on 6/25/24 at 12:15 P.M, the Human Resources Business Partner said that Nurse Aide Registry checks should have been completed for each of the employees.”

“An onsite Centers for Medicare and Medicaid Services (CMS) authorized Critical Access Hospital (CAH) conversion/initial certification survey was completed at North Adams Regional Hospital, located at 71 Hospital Avenue, North Adams, MA. 01247, on 06/24/2024. Please refer to the Medicare Conditions of Participation for Critical Access Hospitals 42 CFR, Part 485, Subpart F. In accordance with the requirements for §485.623 Condition of Participation: Physical plant and environment, (C) Standard: Life safety from fire and (D) Standard: Building safety, an initial Life Safety Code (LSC) survey was conducted. The facility must meet the requirements of NFPA 101 Life Safety Code (2012 edition) and NFPA 99 Health Care Facilities Code (2012 edition). General Information: The North Adams Critical Access Hospital is located on the grounds of the previously licensed North Adams full service hospital. The CAH occupies the basement level, ground level, first and second floors of a five story (ground, first, second, third and fourth) building. The original building was constructed circa 1963 and additions were added in 2006 and 2014. The North Adams Critical Access Hospital (CAH) consists of the following: -A full basement that includes mechanical spaces, service and maintenance shops, medical records storage, boiler rooms, main and emergency power distribution rooms, a morgue and storage areas. -A ground floor that consists of an Emergency Department, Radiology Department, cafeteria, kitchen, laundry, wound care center, administrative and business offices. -A first floor that consists of administrative and business offices, operating rooms (suite), Endoscopy suite, retail (community) pharmacy, outpatient orthopedics and phlebotomy (blood draw) unit. -A second floor that consists of an 18 bed inpatient unit, in-house pharmacy, Williamstown Medical Center, inpatient rehab, support services (meditation room etc.). Note: The third and fourth floors of the original hospital are not part of the CAH and not subject to survey at this time (there is a two hour fire separation between floors). If these floors are to become part of the Critical Access Hospital (CAH) in the future, an additional Life Safety Code and Emergency Preparedness survey will be required to ensure compliance with the corresponding occupancy chapter. In addition to the above, the following is noted: -The facility is fully protected by both wet and dry automatic sprinkler systems. The dry system protects the facility’s main lobby. Note: There is an anti-freeze loop that protects the facility’s loading dock. -The facility’s emergency power is provided by an 800kW diesel powered generator which provides emergency power to the entire building upon loss of normal power. - The facility is located approximately 1.5 miles from a paid and fully staffed city Fire Station. There were no Life Safety Code (LSC) deficiencies noted at time of survey. A form 2786R was completed and forwarded to CMS.”