Millinocket Regional Hospital

“ORGANIZATIONAL STRUCTURE CFR(s): Organizational Structure This Condition is not met as evidenced by: 48232 Based on document reviews and interviews, the hospital failed to meet the Condition of Participation for Organizational Structure as evidenced by the following: The hospital’s governing body failed to provide oversight over the hospital’s Quality Assurance and Performance Improvement (“QAPI”) program resulting in hospital-wide noncompliance with the hospital’s quality improvement plan (C-0962). The hospital’s governing body failed to provide oversight over the hospital’s policy creation and review process (C-0962). The hospital’s governing body failed to ensure senior members of the hospital leadership including the hospital’s Chief Nursing Officer (“CNO”) were educated on the hospital’s Policy Management Policy (C-0962). The cumulative and ongoing effects of these deficient practices have led to noncompliance with this Condition of Participation. Please see C-0962 for details.”

“QAPI CFR(s): Condition of Participation: Quality Assessment and Performance Improvement Program The CAH must develop, implement, and maintain an effective, ongoing, CAH-wide, data-driven quality assessment and performance improvement (QAPI) program. The CAH must maintain and demonstrate evidence of the effectiveness of its QAPI program. (a) Definitions. For the purposes of this section- Adverse event means an untoward, undesirable, and usually unanticipated event that causes death or serious injury or the risk thereof. Error means the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems; and Medical error means an error that occurs in the delivery of healthcare services. This Condition is not met as evidenced by: 48232 Based on document reviews and interviews, the hospital failed to meet the Condition of Participation for Quality Assessment and Performance Improvement (“QAPI”) Program as evidenced by the following: The hospital failed to ensure the Medical/Surgical (“Med-Surg”) Unit, Laboratory, Housekeeping, Emergency Room (“ER”) also known as the Emergency Department (“ED”), Rehabilitation, Dietary, Operating Room (“OR”), Pharmacy, & Cardiopulmonary departments were consistently collecting and reporting QAPI data to the hospital’s Quality Department (C-1302). The hospital failed to ensure the governing body, also known as “The Board of Trustees,” was aware of the activities of the hospital’s QAPI program including the failure of the hospital’s QAPI program to ensure consistent participation of all of the hospital’s departments (C-1313). The cumulative and ongoing effects of these deficient practices have led to noncompliance with this Condition of Participation. Please see C-1302 & C-1313 for details.”

“LICENSURE, CERT., OR REG OF PERSONNEL CFR(s): Staff of the CAH are licensed, certified, or registered in accordance with applicable Federal, State, and local laws and regulations. This Standard is not met as evidenced by: 45336 Based on document review and interviews, the facility failed to ensure the State law requiring a criminal history record is obtained for individuals who will work in direct contact with a consumer in two (2) of ten (10) personnel files reviewed (Registered Nurse (“RN”) #1 & RN #2.) Findings: The Maine Revised Statutes Annotated, Title 22, Subtitle 2, Part 4, Chapter 401, subsection 1724 states; “Beginning October 1, 2010, a facility or health care provider subject to the licensing or certification processes of chapter 405...shall obtain, prior to hiring an individual who will work in direct contact with a consumer, criminal history record information on that individual, including, at a minimum, criminal history record information from the Department of Public Safety, State Bureau of Identification.” A randomly selected sample of ten (10) personnel files was reviewed to determine compliance with State regulations. Of these records, two (2) of ten (10) employees (RN #1 & RN #2), who were hired on or after October 1, 2010, failed to have evidence of a criminal background check containing a minimum, criminal history record information from the Department of Public Safety, State Bureau of Identification. On May 15, 2025, at approximately 11:45 AM, the Director of Human Resources confirmed RN #1 & RN #2’s personnel records did not have the required criminal background checks.”

“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: 50294 Based on document review, interviews, and observation, the hospital failed to perform morning (“AM”) and night (“PM”) equipment checks in one (1) out of (1) Emergency Departments observed. Findings: Interviews with Vice President of Corporate Compliance/Risk Management/Quality and the Infection Preventionist, confirm there is no policy outlining the requirements to ensure performing equipment checks in the Emergency Department. During administrative document review, May 2025 Emergency Department Daily Check Log, which requires AM/PM checks, showed incomplete documentation of the following equipment checks. - Warmer, missing seven (7) of twelve (12) AM checks and eight (8) out of twelve (12) PM checks. - Blanket Warmer, missing seven (7) of twelve (12) AM checks and eight (8) out of twelve (12) PM checks. - Glidescope, missing six (6) of twelve (12) AM checks and seven (7) out of twelve (12) PM checks. - Intubation Boxes, missing seven (7) of twelve (12) AM checks and seven (7) out of twelve (12) PM checks. - Metal Bin #1, missing twelve (12) of twelve (12) AM checks and three (3) out of twelve (12) PM checks. - Metal Bin #2, missing twelve (12) of twelve (12) AM checks and three (3) out of twelve (12) PM checks. - Oxygen Tree x 2, missing seven (7) of twelve (12) AM checks and nine (9) out of twelve (12) PM checks. - Suction Set Up x 2, missing twelve (12) of twelve (12) AM checks and three (3) out of twelve (12) PM checks. - Two (2) out of three (3) normal saline solutions (NSS) were found without an expiration date in the warmer. Incomplete documentation was verified on 05/12/2025 at 11:45 AM by RN #3, on 05/14/2025 at 11:00 AM by the Vice President of Corporate Compliance/Risk Management/Quality, on 05/15/2025 at 10:25 AM by RN #4, and at 10:40 AM by RN #5.”

“DRUG AND BIOLOGICALS CFR(s): Drugs and biologicals commonly used in life-saving procedures, including analgesics, local anesthetics, antibiotics, anticonvulsants, antidotes and emetics, serums and toxoids, antiarrythmics, cardiac glycosides, antihypertensives, diuretics, and electrolytes and replacement solutions. This Standard is not met as evidenced by: 50294 Based on interviews, and observation, the hospital failed to ensure two (2) out of three (3) intravenous (“IV”) fluids observed in the warmer in the Emergency Department were labeled with the expiration date and time. Findings: Interviews with Vice President of Corporate Compliance/Risk Management/Quality and the Infection Preventionist confirmed there was no policy outlining the requirements to ensure proper dating/labeling IV fluids that are placed in the warmer for patients use. On 05/12/2025 at 11:45 AM, the surveyor observed during observations of the Emergency Department that two (2) out of three (3) normal saline solutions in the IV fluid warmer were found without an expiration date and time. RN #3 was present during the observation and confirmed these findings.”

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 50294 Based on interviews, and observation, the hospital failed to ensure that three (3) out of three (3) observed intravenous line (“IV”) carts that contained needles and syringes and which were located in a publicly accessible area in the Emergency Department, were locked. (Cardiac room, hallway, and trauma room) Finding: On 05/12/2025 at 11:50 AM the surveyor observed IV carts located in the cardiac room, hallway, and trauma room of the Emergency Department were left unlocked. This was confirmed by RN #3 and the Chief Nursing Officer who were present at the time of observation.”

“PREMISES ARE CLEAN AND ORDERLY CFR(s): (4) The premises are clean and orderly; and This Standard is not met as evidenced by: 46424 Based on observations and interviews, the hospital failed to maintain a clean and uncluttered physical environment. Cracked floor tiles, stained ceiling tiles, and cluttered hallways were identified during the survey. Findings: The following floor tiles were observed in disrepair: - On 5/12/2025 on a tour of the hospital, cracked floor tiles were noted in the utility rooms on the Medical-Surgery unit at 2:26 PM and 2:48 PM. This created surfaces which could not be easily cleaned and sanitized. The Maintenance Engineer confirmed these findings at the time of observation. - On 5/13/2025 on a tour of the hospital, cracked floor tiles were noted on the ground floor hallway by the cafeteria at 12:15 PM. This created surfaces which could not be easily cleaned and sanitized. The Maintenance Engineer confirmed these findings on 5/15/2025 at 10:35 AM. - On 5/15/2025 on a tour of the hospital, cracked floor tiles were noted in the ground floor hallway by the elevator at 8:33 AM. This created a surface which could not be easily cleaned and sanitized. The Maintenance Engineer confirmed these findings on 5/15/2025 at 10:33 AM. The following ceiling tiles were observed in disrepair: -On 5/12/2025 on a tour of the hospital, stained ceiling tiles were noted in the Pharmacy at 1:42 PM. -On 5/12/2025 on a tour of the hospital, stained ceiling tiles were noted in the Soiled Utility Room and Electrical Utility Room on the 2nd floor at 2:27 PM and 2:34 PM. This was confirmed with the Maintenance Engineer at the time of observation. -On 5/13/2025 on a tour of the hospital, stained and missing ceiling tiles were noted in the Emergency Department at 10:18 AM. This was confirmed with the Vice President of Corporate Compliance/Risk Management/Quality at the time of observation. -On 5/13/2025 on a tour of the offsite Physical Therapy practice, stained ceiling tiles were noted at this location at 2:24 PM and 2:29 PM. This was confirmed with the Physical Therapy Coordinator at the time of observation. Clutter in hallways was observed: -On a tour of the hospital on 5/12/2025, stored equipment was noted in the hallway by the exit on the Medical-Surgical unit at 2:07 PM. -On a tour of the hospital on 5/13/2025, stored equipment was noted in the hallway by the back exit on the ground floor at 12:16 PM. The Maintenance Engineer confirmed these findings at the time of observation.”

“PROPER VENTILATION, LIGHTING, AND TEMPERATURE CFR(s): (5) There is proper ventilation, lighting, and temperature control in all pharmaceutical, patient care, and food preparation areas. This Standard is not met as evidenced by: 45336 Based on document reviews and interviews the hospital failed to maintain the temperature and humidity in the procedure rooms and the Central Sterile Room (“CSR”), according to the 2025 Association of perioperative Registered Nurses (“AORN”) standards, the standards the hospital adopted. Findings: The 2022 Association of perioperative Registered Nurses (“AORN”) Edition page 97 contains standards related to temperature and humidity in the following areas: Procedure Rooms 30% to 60% humidity; Sterile Processing Clean Assembly Workroom maximum 60% humidity and temperature 68 to 73 degrees Fahrenheit. The Millinocket Regional Hospital policy titled, “Environment Humidity, Air Temperature in Surgical Areas, last reviewed 08/02/2022, stated in part, “Room temperature and humidity will be recorded by the following: a. By operating room personnel on the Intra-Operative Record b. A log will be maintained in the OR Registry Log Book”. On 05/14/2025, at 9:45 AM, an interview was conducted with Operating Room (“OR”) Director, regarding the documentation of the Operating Room Temperatures and Humidity. She was asked if she completed the documentation of the temperature and humidity logs in the OR Registry Log Book. She stated there were no OR Registry Log Books with a record of operating room temperatures and humidity.”

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. This Standard is not met as evidenced by: 48232 Based on document reviews and interviews, the hospital’s governing body failed to provide oversight over the hospital’s Quality Assurance and Performance Improvement (“QAPI”) program resulting in hospital-wide noncompliance with the hospital’s quality improvement plan. Findings: Millinocket Regional Hospital’s Quality Improvement Plan for 2024 states in part: “...Professional Affairs Committee: The Professional Affairs Committee (PAC) is a multidisciplinary group that is designated by the Board of Trustees to provide oversight and direction for the quality and performance improvement program... The PAC shall consist of at least two Board Trustees, one physician, one to two allied health professionals, Senior Leadership to include the CEO, CNO, CQO, and CFO. PAC meetings will be scheduled on a quarterly basis. Activities include but are not limited to: 1.Assisting the Governing Board and the MSEC with the development and evaluation of the Quality Improvement Plan ...Receive and review the reports regarding the effectiveness of MRH’s hospital wide QAPI (Quality Assurance Performance Improvement) activities...Act upon data reviewed...Reporting to the Board of Trustees... Governing Board: The Board of Trustees shall be responsible to ensure optimal quality care, safety, and organization-wide performance are provided. The Board is ultimately responsible for the safety and quality of patient care provided in every department and service of the hospital. The Board has legal responsibility and authority of hospital performance. The Board delegates operational responsibility to the Medical Staff and Administration. The Board shall facilitate the Quality Program by: 1.Authorizing the Professional Affairs Committee to implement the QAPl (Quality Assurance Performance Improvement) Program...Establish an organization wide structure that supports a commitment to quality and patient safety...Ensure the quality program reflects the hospital’s organization and services...Receives reports of QAPI data from all departments and services of the hospital, including contracted services... Hospital Departments: The Department Leaders are accountable for the quality and safety of care/services and performance of their staff and departments. Department Directors and Managers are responsible for the systematic monitoring and analysis of the quality and safety of care provided in their departments. Directors will: 1.Prioritize and communicate opportunities for improvement relating to their department. 2.Monitor, analyze and report the processes in their areas that affect patient care, safety, outcomes and satisfaction...Participate in the quality improvement team and report QAPI data evaluated and actions taken as appropriate... Data Collection: The department staff will collect, organize and analyze data performance benchmarks. Data will be organized to facilitate comparison and trends. Tools include but are not limited to control charts, graphs, and run charts. The data collected will be collected and reported in a timely and efficient manner. Frequency of Data Collection: Data will be collected by designated department staff on a quarterly basis. The frequency of data collection may require more detail and frequency based upon priority issues and adverse or significant events...” During an in-person interview on 05/13/2025 at 1:05 PM, the Vice President of Corporate Compliance/Risk Management/Quality indicated that the hospital’s QAPI committee was called the Corporate Compliance and Professional Affairs Committee (“PAC”). She stated the PAC was the only quality (QAPI) committee at the hospital. She stated they did not have discussions about specific quality data at the [PAC], and she stated that the quality committee (PAC) was “not a very active committee.” On 05/13/2025 at 1:20 PM, the Vice President of Corporate Compliance/Risk Management/Quality indicated that unless there was a concern or issue, the Quality Department would not discuss quarterly quality information with the board/governing body. She additionally confirmed that the governing body were not aware of all of the other functions of the QAPI (PAC) committee. A review of Millinocket Regional Hospital’s Professional Affairs Committee meeting minutes for 2024 revealed that the Professional Affairs Committee only met two (2) times in 2024 (03/01/2024 & 12/09/2024) and that no physician was present for either of the two (2) Professional Affairs Committee meetings. Board of Trustees meeting minutes were reviewed for 12/09/2024, 01/27/2025, 02/24/2025, 06/24/2024, 07/29/2024, 09/16/2024, 10/28/2024, 03/31/2025 and the meeting minutes did not reveal evidence of the discussion of any specific QAPI data. The meeting minutes revealed a section titled, “Professional Affairs/Corporate Compliance Committee,” and each of the reviewed meeting minutes revealed either of the following statement, “...No pressing issues to bring to the Board...,” or “...The committee did not meet since the last Board meeting...” One (1) of the meeting minutes did not mention the Professional Affairs/Corporate Compliance Committee at all. The Vice President of Corporate Compliance/Risk Management/Quality confirmed on 05/14/2025 at 11:12 AM that the department directors were supposed to be reporting quality data to her but were failing to do so, she confirmed that the governing body was not discussing QAPI at board meetings. During a telephone interview with Board Member #1 on 05/14/2025 at 1:33 PM, when Board Member #1 was questioned regarding why the governing body/board meeting minutes from the past two (2) (02/24/2025 & 03/31/2025) board meetings did not show any information from quality, he stated the board, “must not have talked about any of it.” When Board Member #1 was questioned regarding why the PAC committee meeting minutes for 2024 did not show evidence that there was any discussion of quality measures during the PAC meetings, he stated it sounded to him like they (the PAC), “hadn’t done a quality discussion at those meetings.” He confirmed that that it was his responsibility to review the quality information from the Professional Affairs Committee and take it to the board at the board meeting. During an in-person interview on 05/15/2025 at 10:24 AM. The Vice President of Corporate Compliance/Risk Management/Quality stated the managers were not providing quality information to her. She stated she had asked for quality data and stated some of the managers were good about doing it and some “just don’t know what to do.” She stated she had offered to help the department managers to develop quality measures, but “they [the department managers] are just not doing it.” She stated she had escalated her concerns about this to the Chief Executive Officer, (“CEO”). She stated the plan was that if the managers didn’t report their quality data, [the department managers] would have to come in person to the Professional Affairs Committee meeting to explain why, “but that did not happen.” During the in-person interview on 05/15/2025 at 10:24 AM, the Vice President of Corporate Compliance/Risk Management/Quality confirmed that she attended all of the Professional Affairs Committee meetings, and stated she ran the meetings. She stated that less than half of the hospital’s quality data was presented to board members during the PAC meetings. She stated it was the board members’ responsibility to bring the quality data from the PAC meetings to the governing body at the board meetings. She stated the board members didn’t get any of the quality data at the board/governing body meetings, and stated [the board members] just get the “30,000 feet” if there was any concern. She stated QAPI data didn’t flow up to the board at all unless there was a concern. She stated only the governing body members that sit on the PAC committee had input on QAPI measures, and she indicated this only included two (2) board members - Board Member #1, and the Board President. A document titled, “Quality Summary,” was provided to the survey team on 05/15/2025 by the hospital’s Vice President of Corporate Compliance/Risk Management/Quality. A review of the document revealed the following information: -No Quality information was reported for Med-Surg for Quarter #3 2023, Quarter #1 2024, Quarter #3 2024, Quarter #4 2024, & Quarter #1 2025 -No Quality information was reported for the Lab for Quarter #3 2024, Quarter #4 2024 -No Quality information was reported for Housekeeping for Quarter #1 2025 -No Quality information was reported for the Emergency Room (“ER”) also known as the Emergency Department (“ED”) for Quarter #1 2024, Quarter #2 2024 -No Quality information was reported for Rehab for Quarter #3 2024, -No Quality information was reported for Dietary for Quarter #4 2024, & Quarter #1 2025 -No Quality information was reported for the Operating Room for Quarter #1 2024, Quarter #2 2024, Quarter #3 2024, Quarter #4 2024, & Quarter #1 2025 -Quality information was blank for the Pharmacy or Quarter #1 2024, Quarter #2 2024, Quarter #3 2024, & Quarter #4 2024 -No Quality information was reported for Cardiopulmonary for Quarter #2 2024, Quarter #3 2024, Quarter #4 2024, & Quarter #1 2025 On 05/15/2025 at 10:24 AM the Vice President of Corporate Compliance/Risk Management/Quality reviewed the above information with the survey team and confirmed the information was correct and that no quality data was reported by these departments during these quarters. On 05/15/2025 at 11:03 AM the Board President (President of the Board of Trustees also known as the hospital’s governing body) confirmed during an in-person interview that she was the president of the board and a member of the PAC. She indicated that she was responsible for bringing the information from the PAC to the board meetings. She stated the information about quality that they got at the PAC meetings were information about the quality plan, who had reported their quality data and who hadn’t, as well as what the plan was to receive the data that hadn’t been reported. She stated she did not recall seeing a lot of the actual quality reports themselves. She stated it was typically only if there was an issue. She stated quality wasn’t reviewed at every PAC meeting, and she stated specific quality measures were not shared with the board each quarter. She stated she did not recall the specific quality measures being shared at the board meetings in a “long time,” and over the past 10 years the board had left, “all of the operation things to the administration team.” She stated the board got a “30,000 foot view of everything quality,” to try to steer the direction without, “being in the middle of day to day stuff.” She added that the board designated the CEO as the person responsible for all of the, “operational stuff.” She stated the board, “has been so heavily focused on finance we have run out of time to do everything else,” and she stated that as the president of the board, she did not know that many departments had not reported quality data for most of [2024]. On 05/15/2025 at 11:13 AM the Board President reviewed the document titled, “Quality Summary” with the surveyor which included a review of the following data: -No Quality information was reported for Med-Surg for Quarter #3 2023, Quarter #1 2024, Quarter #3 2024, Quarter #4 2024, & Quarter #1 2025 -No Quality information was reported for the Lab for Quarter #3 2024, Quarter #4 2024 -No Quality information was reported for Housekeeping for Quarter #1 2025 -No Quality information was reported for the Emergency Room (“ER”) also known as the Emergency Department (“ED”) for Quarter #1 2024, Quarter #2 2024 -No Quality information was reported for Rehab for Quarter #3 2024, -No Quality information was reported for Dietary for Quarter #4 2024, & Quarter #1 2025 -No Quality information was reported for the Operating Room for Quarter #1 2024, Quarter #2 2024, Quarter #3 2024, Quarter #4 2024, & Quarter #1 2025 -Quality information was blank for the Pharmacy or Quarter #1 2024, Quarter #2 2024, Quarter #3 2024, & Quarter #4 2024 -No Quality information was reported for Cardiopulmonary for Quarter #2 2024, Quarter #3 2024, Quarter #4 2024, & Quarter #1 2025 Following the review, the Board President stated she was not aware that quality data was not reported by these departments in the above quarters. The Board President stated the board was not aware of the missing quality data either. Based on document reviews and interviews, the hospital’s governing body failed to provide oversight over the hospital’s policy creation and review process. Findings: Millinocket Regional Hospital’s policy titled, “MRH Policy Management,” (not dated) states in part: “...1. Policies in all areas and departments of the hospital will be developed, approved and revised with consideration of input from key stakeholders of the related content. 2. For policies and procedures involving ‘patient care’ services, the process of development, approval, revision and review will include consideration of the advice of a group or committee whose membership includes at least one doctor of medicine or osteopathy and one or more physician assistants, nurse practitioners and clinical nurse specialist on staff. 3.All policies are required to be reviewed biennially by such group or committee and whenever necessary to assure compliance with accepted practice, regulations and standards...” The Vice President of Corporate Compliance/Risk Management/Quality confirmed via an email (“Email #1”) sent to the survey team on 05/13/2025 at 7:28 PM that the hospital’s policies were required to be reviewed every two (2) years. On 05/14/2025 at 12:37 PM, the survey team sent an email request (“Email #2”) for a master list of all policies showing the last date each of those policies was reviewed. On 05/14/2025, the hospital provided a document to the survey team titled, “MRH Active Policy Documents with All Revision Dates,” which the Vice President of Corporate Compliance/Risk Management/Quality indicated was a list of all of the hospitals policies, including the date the policies were last reviewed. A review of the document revealed that one-hundred-thirty-two (132) out of the two-hundred-fifteen (215), or approximately sixty-one percent (61%) of the hospital’s policies, had not been reviewed in over two (2) years with last reviewed dates going as far back as the year two-thousand-nineteen (2019). Based on document reviews and interviews the hospital’s governing body failed to ensure senior members of the hospital leadership including the hospital’s Chief Nursing Officer (“CNO”) were educated on the hospital’s Policy Management Policy. Findings: Millinocket Regional Hospital’s policy titled, “MRH Policy Management,” (not dated) states in part: “...1. Policies in all areas and departments of the hospital will be developed, approved and revised with consideration of input from key stakeholders of the related content. 2.For policies and procedures involving ‘patient care’ services, the process of development, approval, revision and review will include consideration of the advice of a group or committee whose membership includes at least one doctor of medicine or osteopathy and one or more physician assistants, nurse practitioners and clinical nurse specialist on staff...” On 05/15/2025 at 8:53 AM the survey team received an email (“Email #3”) which stated in part, “...Good Morning, While searching for these policies to deliver as requested, it is apparent that when our policies were compromised last summer, those policies were not recovered. As the new CNO, to close that gap, I have created new policies that staff will be educated on, and they will be uploaded to our policy library. Please see new attached policies ...” The email included attached policies titled, “Medication Ordered STAT and at Specified Time Intervals, Adverse Drug Reaction Definition and Process, & Telephone and Verbal Order Policy.” During an in-person interview on 05/15/2025 at 9:23 AM, the CNO stated there, “was a gap so I rewrote some policies.” The CNO stated she created the policies and stated she started working on the policies [on 05/14/2025]. The CNO stated she, “created the policies from scratch.” When the CNO was questioned as whether or not she had to have policies and procedures approved by the governing body before instituting them, she stated she did not know the answer.”

“PATIENT CARE POLICIES CFR(s): §485.635(a)(2) The policies are developed with the advice of members of the CAH’s professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1). §485.635(a)(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. This Standard is not met as evidenced by: 48232 Based on document reviews and interviews, the hospital failed to ensure that one-hundred-thirty-two (132) out of two-hundred-fifteen (215) policies had been reviewed within two (2) years prior to the date of the initiation of the survey (05/12/2025). Findings: Millinocket Regional Hospital’s policy titled, “MRH Policy Management,” (not dated) states in part: “...All policies are required to be reviewed biennially by such group or committee and whenever necessary to assure compliance with accepted practice, regulations and standards...” The Vice President of Corporate Compliance/Risk Management/Quality confirmed via an email (“Email #1”) sent to the survey team on 05/13/2025 at 7:28 PM that the hospital’s policies were required to be reviewed every two (2) years. On 05/14/2025 at 12:37 PM, the survey team sent an email request (“Email #2”) for a master list of all policies showing the last date each of those policies was reviewed. On 05/14/2025, the hospital provided a document to the survey team titled, “MRH Active Policy Documents with All Revision Dates,” which the Vice President of Corporate Compliance/Risk Management/Quality indicated was a list of all of the hospitals policies, including the date the policies were last reviewed. A review of the document revealed that one-hundred-thirty-two (132) out of the two-hundred-fifteen (215), or approximately sixty-one percent (61%) of the hospital’s policies, had not been reviewed in over two (2) years with last reviewed dates going as far back as the year two-thousand-nineteen (2019). The document titled, “MRH Active Policy Documents with All Revision Dates,” additionally revealed the following information related to specific service areas/departments: -The hospital failed ensure sixty-seven percent (67%) of Central Sterile policies were reviewed -The hospital failed to ensure fifty-seven percent (57%) of Nursing policies were reviewed -The hospital failed to ensure seventy-two (72%) of Operating Room policies were reviewed -The hospital failed to ensure one-hundred percent (100%) of Radiology policies were reviewed -The hospital failed to ensure one-hundred percent (100%) of Rehabilitation policies were reviewed”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (v) Procedures for reporting adverse drug reactions and errors in the administration of drugs. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure that 1)policies and procedures were available to nursing staff for adverse drug reactions and 2)that leadership was able to identify an adverse drug reaction. Findings: In an American Society of Health-System Pharmacists (“ASHP”) Adverse Drug Reaction Reporting article by Lee B. Murdaugh, RPh, PhD, he states in part, “The Conditions of Participation standards of the Centers for Medicare & Medicaid Services (CMS) and the standards of accrediting organizations such as The Joint Commission, the Healthcare Facilities Accreditation Program (HFAP), and the National Integrated Accreditation for Healthcare Organizations (NIAHOSM) require hospitals to identify and report adverse drug reactions (ADRs). These ADRs must be reported to patients’ attending physicians and the hospital’s quality assessment and performance improvement program.” On 05/12/2025, a request was made to the Vice President of Corporate Compliance/Risk Management/Quality for the adverse drug reaction and medication error policies and procedures. On 05/15/2025 at 8:53 AM, after several requests for some nursing policies and procedures, the Chief Nursing Officer (“CNO”) sent an email stating, “While searching for these policies to deliver as requested, it is apparent that when our policies were compromised last summer, those policies were not recovered. As the new CNO, to close that gap, I have created new policies that staff will be educated on, and they will be uploaded to our policy library. Please see new attached policies.” On 05/15/2025 at 9:23 AM, an interview was conducted with the CNO. She was asked about the new policies she created “last night” and the policy process. She stated the following: - There was a compromise and they lost the policies and that was a gap; - I re-wrote the policies, through internal policy and got with the supervisor and talked about the guidelines; - I am able to put them in the [online] library and an all-staff meeting will go out today; - For new policies, I review them with the [nursing] supervisors and I would review them with [the Vice President of Compliance]; and - We had a previous policy but we were not able to find them. On 05/15/2025 at 9:34 AM, an interview was conducted with the Chief Executive Officer (“CEO”). He was asked if he was aware that new policies and procedures were created and ready to be provided to staff today. He stated, “If she started a policy this week, I would not be aware of that.” On 05/15/2025 at 9:48 AM, an interview was conducted with the Information Technology Director and he was asked about a computer breech that occurred on 07/20/2024. He stated that they got a small amount of user files (Documents that people created on their own computers ). However, the policies and procedures are web based and not affected. On 05/15/2025 at 11:01 AM, after several requests, the Vice President of Corporate Compliance/Risk Management/Quality sent an email stating, “We had no reported adverse drug reactions. Thank you.” With this email, she attached a document titled, “Medication Error Report JAN 2024-PRESENT”. This report contained information that there was, in fact, an adverse drug reaction on 02/04/2025. Further documentation was requested. The documentation provided shows the steps necessary for a complete review of this incident, which was not completed. Due to leadership not identifying this adverse drug reaction, it was not reported to the Quality Committee for review.”

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure that nursing staff personnel files contained evidence of competency training to ensure that they could meet the needs of the patients for six (6) of twelve (12) nurses reviewed (Registered Nurse #3 - #8). Findings: On 05/15/2025 at 1:45 PM, the policies and procedures for new hires was requested however, the Director of Human Resources did not provide the information. On 05/15/2025 at 10:05 AM, the Vice President of Corporate Complaince/Risk Management/Quality stated the hospital does not have an Emergency Department nurse manager. The Chief Nursing Officer stated the supervisors would have the nurse competency documents in their office, however, the Director of Human Resources was able to provide the information. On 05/15/2025 at 1:50 PM, a review of twelve (12) nursing files were provided by the Director of Human Resources. The following was identified: - Registered Nurse (“RN”) #3’s date of hire is 01/10/2022; - RN #4’s date of hire is 12/22/2021; - RN #5’s date of hire is 08/19/2024; - RN #6’s date of hire is 08/30/2024; - RN #7’s date of hire is 10/01/2024; - RN #8’s date of hire is 09/01/2024; and - As of 05/15/2025, the required nursing competencies have not been completed.”

“RECORDS SYSTEM CFR(s): The records are legible, complete, accurately documented, readily accessible, and systematically organized. This Standard is not met as evidenced by: 50294 Based on document review and interviews, the hospital failed to ensure Emergency Severity Index (ESI) was documented in one (1) out of ten (10) clinical records in the Emergency Department. (Patient #9) Findings: The hospital’s policy titled, Emergency Department Triage, effective 03/22/2019, defines ESI as “A five level triage scoring system used to facilitate the prioritization of patients based on the urgency of patient condition.” The policy states in part, “...All patients presenting to Millinocket Regional Hospital’s Emergency Department will be evaluated by an appropriately trained registered nurse who will categorize each patient using the ESI levels of priority upon arrival to the Emergency Department 24 hours a day 7 days a week...” During a clinical record review on 05/14/2025 at 9:30 AM, Patient #9’s medical record was reviewed and revealed that no ESI was documented. The Vice President of Corporate Compliance/Risk Management/Quality and the Infection Preventionist, confirmed these findings.”

“RECORDS SYSTEM CFR(s): For each patient receiving health care services, the CAH maintains a record that includes, as applicable-- (i) Identification and social data, evidence of properly executed informed consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient; This Standard is not met as evidenced by: 50294 Based on document review and interviews, the hospital failed to ensure that informed consent forms were obtained for one (1) out of ten (10) patient records reviewed (Patient #9). Findings: During a clinical record review on 05/14/2025 at 10:05 AM, patient #9’s medical record was reviewed and revealed that no informed consent was obtained. The Vice President of Corporate Compliance/Risk Management/Quality and the Infection Preventionist, confirmed these findings during the clinical record review.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 46424 Based on observations and interviews, the hospital failed to maintain a clean and sanitary environment to avoid sources and transmission of infection. Findings: The following was found in disrepair: - On 5/12/2025 on a tour of the hospital at 1:15 PM, tears in the upholstery of a sofa in the 2nd floor Family Room were noted. This created surfaces which could not be easily cleaned and sanitized. - On 5/12/2025 on a tour of the hospital at 2:15 PM in Room 214 of the Special Care Unit, black tape loosely covering a vent in the ceiling and an exposed patch of the wall were observed. This created surfaces which could not be easily cleaned and sanitized. These findings were confirmed by the Maintenance Engineer at the time of observation. On 5/13/2025 on a tour of the lab area at 8:15 AM, an arm on a phlebotomy chair with a rip that was taped over with clear tape was observed. This created a surface which could not be easily cleaned and sanitized. This finding was confirmed by the Vice President of Corporate Compliance/Risk Management/Quality at the time of observation. On 5/13/2025 on a tour of the offsite Surgery and Urology practice at 11:40 AM, a Urology examination table with rips in 2 corners was noted. This created a surface which could not be easily cleaned and sanitized. This finding was confirmed with the Practice Manager at the time of observation.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (1) Be appropriate for the complexity of the CAH’s organization and services provided. This Standard is not met as evidenced by: 48232 Based on document reviews and interviews, the hospital failed to ensure the Med-Surg Unit, Laboratory, Housekeeping, ER, Dietary, Operating Room, Pharmacy and Cardiopulmonary departments were consistently collecting and reporting QAPI data to the hospital’s Quality Department. Findings: Millinocket Regional Hospital’s Quality Improvement Plan for 2024 states in part, “...Data Collection: The department staff will collect, organize and analyze data performance benchmarks. Data will be organized to facilitate comparison and trends. Tools include but are not limited to control charts, graphs, and run charts. The data collected will be collected and reported in a timely and efficient manner. Frequency of Data Collection: Data will be collected by designated department staff on a quarterly basis. The frequency of data collection may require more detail and frequency based upon priority issues and adverse or significant events...” On 05/14/2025 at 11:11 AM, the Vice President of Corporate Compliance/Risk Management/Quality confirmed that the department directors were supposed to be reporting quality data to her, but were failing to do so. During an in-person interview on 05/15/2025 at 10:24 AM. The Vice President of Corporate Compliance/Risk Management/Quality stated the managers were not providing quality information to her. She stated she had asked for quality data and stated some of the managers were good about doing it and some “just don’t know what to do.” She stated she had offered to help the department managers to develop quality measures, but “they [the department managers] are just not doing it.” She stated she had escalated her concerns about this to the Chief Executive Officer, (“CEO”). She stated the plan was that if the managers didn’t report their quality data, [the department managers] would have to come in person to the Professional Affairs Committee meeting to explain why, “but that did not happen.” A document titled, “Quality Summary,” was provided to the survey team on 05/15/2025 by the hospital’s Vice President of Corporate Compliance/Risk Management/Quality. A review of the document revealed the following information: -No Quality information was reported for Med-Surg for Quarter #3 2023, Quarter #1 2024, Quarter #3 2024, Quarter #4 2024, & Quarter #1 2025 -No Quality information was reported for the Lab for Quarter #3 2024, Quarter #4 2024 -No Quality information was reported for Housekeeping for Quarter #1 2025 -No Quality information was reported for the Emergency Room (“ER”) also known as the Emergency Department (“ED”) for Quarter #1 2024, Quarter #2 2024 -No Quality information was reported for Rehab for Quarter #3 2024, -No Quality information was reported for Dietary for Quarter #4 2024, & Quarter #1 2025 -No Quality information was reported for the Operating Room for Quarter #1 2024, Quarter #2 2024, Quarter #3 2024, Quarter #4 2024, & Quarter #1 2025 -Quality information was blank for the Pharmacy or Quarter #1 2024, Quarter #2 2024, Quarter #3 2024, & Quarter #4 2024 -No Quality information was reported for Cardiopulmonary for Quarter #2 2024, Quarter #3 2024, Quarter #4 2024, & Quarter #1 2025 On 05/15/2025 at 10:24 AM the Vice President of Corporate Compliance/Risk Management/Quality reviewed the above information with the survey team and confirmed the information was correct and that no quality data was reported by these departments during these quarters.”

“QAPI CFR(s): (c) Standard: Governance and leadership. The CAH’s governing body or responsible individual is ultimately responsible for the CAH’s QAPI program and is responsible and accountable for ensuring that the QAPI program meets the requirements of paragraph (b) of this section. This Standard is not met as evidenced by: 48232 Based on document reviews and interviews, the hospital failed to ensure the governing body, also known as “The Board of Trustees,” was aware of the activities of the hospital’s QAPI program including the failure of the hospital’s QAPI program to ensure consistent participation of all of the hospital’s departments Findings: Millinocket Regional Hospital’s Quality Improvement Plan for 2024 states in part: “...Professional Affairs Committee: The Professional Affairs Committee (PAC) is a multidisciplinary group that is designated by the Board of Trustees to provide oversight and direction for the quality and performance improvement program... The PAC shall consist of at least two Board Trustees, one physician, one to two allied health professionals, Senior Leadership to include the CEO, CNO, CQO, and CFO. PAC meetings will be scheduled on a quarterly basis. Activities include but are not limited to: 1.Assisting the Governing Board and the MSEC with the development and evaluation of the Quality Improvement Plan ...Receive and review the reports regarding the effectiveness of MRH’s hospital wide QAPI (Quality Assurance Performance Improvement) activities...Act upon data reviewed...Reporting to the Board of Trustees... Governing Board: The Board of Trustees shall be responsible to ensure optimal quality care, safety, and organization-wide performance are provided. The Board is ultimately responsible for the safety and quality of patient care provided in every department and service of the hospital. The Board has legal responsibility and authority of hospital performance. The Board delegates operational responsibility to the Medical Staff and Administration. The Board shall facilitate the Quality Program by: 1.Authorizing the Professional Affairs Committee to implement the QAPl (Quality Assurance Performance Improvement) Program...Establish an organization wide structure that supports a commitment to quality and patient safety...Ensure the quality program reflects the hospital’s organization and services...Receives reports of QAPI data from all departments and services of the hospital, including contracted services... Hospital Departments: The Department Leaders are accountable for the quality and safety of care/services and performance of their staff and departments. Department Directors and Managers are responsible for the systematic monitoring and analysis of the quality and safety of care provided in their departments. Directors will: 1.Prioritize and communicate opportunities for improvement relating to their department. 2.Monitor, analyze and report the processes in their areas that affect patient care, safety, outcomes and satisfaction...Participate in the quality improvement team and report QAPI data evaluated and actions taken as appropriate... Data Collection: The department staff will collect, organize and analyze data performance benchmarks. Data will be organized to facilitate comparison and trends. Tools include but are not limited to control charts, graphs, and run charts. The data collected will be collected and reported in a timely and efficient manner. Frequency of Data Collection: Data will be collected by designated department staff on a quarterly basis. The frequency of data collection may require more detail and frequency based upon priority issues and adverse or significant events...” During an in-person interview on 05/13/2025 at 1:05 PM, the Vice President of Corporate Compliance/Risk Management/Quality indicated that the hospital’s QAPI committee was called the Corporate Compliance and Professional Affairs Committee (“PAC”). She stated the PAC was the only quality (QAPI) committee at the hospital. She stated they did not have discussions about specific quality data at the [PAC], and she stated that the quality committee (PAC) was “not a very active committee.” On 05/13/2025 at 1:20 PM, the Vice President of Corporate Compliance/Risk Management/Quality indicated that unless there was a concern or issue, the Quality Department would not discuss quarterly quality information with the board/governing body. She additionally confirmed that the governing body were not aware of all of the other functions of the QAPI (PAC) committee. A review of Millinocket Regional Hospital’s Professional Affairs Committee meeting minutes for 2024 revealed that the Professional Affairs Committee only met two (2) times in 2024 (03/01/2024 & 12/09/2024) and that no physician was present for either of the two (2) Professional Affairs Committee meetings. Board of Trustees meeting minutes were reviewed for 12/09/2024, 01/27/2025, 02/24/2025, 06/24/2024, 07/29/2024, 09/16/2024, 10/28/2024, 03/31/2025 and the meeting minutes did not reveal evidence of the discussion of any specific QAPI data. The meeting minutes revealed a section titled, “Professional Affairs/Corporate Compliance committee, and each of the reviewed meeting minutes revealed either of the following statement, “...No pressing issues to bring to the Board...,” or “...The committee did not meet since the last Board meeting...” One (1) of the meeting minutes did not mention the Professional Affairs/Corporate Compliance Committee at all. The Vice President of Corporate Compliance/Risk Management/Quality confirmed on 05/14/2025 at 11:12 AM that the department directors were supposed to be reporting quality data to her but were failing to do so, she confirmed that the governing body was not discussing QAPI at board meetings. During a telephone interview with Board Member #1 on 05/14/2025 at 1:33 PM, when Board Member #1 was questioned regarding why the governing body/board meeting minutes from the past two (2) (02/24/2025 & 03/31/2025) board meetings did not show any information from quality, he stated the board, “must not have talked about any of it.” When Board Member #1 was questioned regarding why the PAC committee meeting minutes for 2024 did not show evidence that there was any discussion of quality measures during the PAC meetings, he stated it sounded to him like they (the PAC), “hadn’t done a quality discussion at those meetings.” He confirmed that that it was his responsibility to review the quality information from the Professional Affairs Committee and take it to the board at the board meeting. During an in-person interview on 05/15/2025 at 10:24 AM. The Vice President of Corporate Compliance/Risk Management/Quality stated the managers were not providing quality information to her. She stated she had asked for quality data and stated some of the managers were good about doing it and some “just don’t know what to do.” She stated she had offered to help the department managers to develop quality measures, but “they [the department managers] are just not doing it.” She stated she had escalated her concerns about this to the Chief Executive Officer, (“CEO”). She stated the plan was that if the managers didn’t report their quality data, [the department managers] would have to come in person to the Professional Affairs Committee meeting to explain why, “but that did not happen.” During the in-person interview on 05/15/2025 at 10:24 AM, the Vice President of Corporate Compliance/Risk Management/Quality confirmed that she attended all of the Professional Affairs Committee meetings, and stated she ran the meetings. She stated that less than half of the hospital’s quality data was presented to board members during the PAC meetings. She stated it was the board members’ responsibility to bring the quality data from the PAC meetings to the governing body at the board meetings. She stated the board members didn’t get any of the quality data at the board/governing body meetings, and stated [the board members] just get the “30,000 feet” if there was any concern. She stated QAPI data didn’t flow up to the board at all unless there was a concern. She stated only the governing body members that sit on the PAC committee had input on QAPI measures, and she indicated this only included two (2) board members - Board Member #1, and the Board President. A document titled, “Quality Summary,” was provided to the survey team on 05/15/2025 by the hospital’s Vice President of Corporate Compliance/Risk Management/Quality. A review of the document revealed the following information: -No Quality information was reported for Med-Surg for Quarter #3 2023, Quarter #1 2024, Quarter #3 2024, Quarter #4 2024, & Quarter #1 2025 -No Quality information was reported for the Lab for Quarter #3 2024, Quarter #4 2024 -No Quality information was reported for Housekeeping for Quarter #1 2025 -No Quality information was reported for the Emergency Room (“ER”) also known as the Emergency Department (“ED”) for Quarter #1 2024, Quarter #2 2024 -No Quality information was reported for Rehab for Quarter #3 2024, -No Quality information was reported for Dietary for Quarter #4 2024, & Quarter #1 2025 -No Quality information was reported for the Operating Room for Quarter #1 2024, Quarter #2 2024, Quarter #3 2024, Quarter #4 2024, & Quarter #1 2025 -Quality information was blank for the Pharmacy or Quarter #1 2024, Quarter #2 2024, Quarter #3 2024, & Quarter #4 2024 -No Quality information was reported for Cardiopulmonary for Quarter #2 2024, Quarter #3 2024, Quarter #4 2024, & Quarter #1 2025 On 05/15/2025 at 10:24 AM the Vice President of Corporate Compliance/Risk Management/Quality reviewed the above information with the survey team and confirmed the information was correct and that no quality data was reported by these departments during these quarters. On 05/15/2025 at 11:03 AM the Board President (President of the Board of Trustees also known as the hospital’s governing body) confirmed during an in-person interview that she was the president of the board and a member of the PAC. She indicated that she was responsible for bringing the information from the PAC to the board meetings. She stated the information about quality that they got at the PAC meetings were information about the quality plan, who had reported their quality data and who hadn’t, as well as what the plan was to receive the data that hadn’t been reported. She stated she did not recall seeing a lot of the actual quality reports themselves. She stated it was typically only if there was an issue. She stated quality wasn’t reviewed at every PAC meeting, and she stated specific quality measures were not shared with the board each quarter. She stated she did not recall the specific quality measures being shared at the board meetings in a “long time,” and over the past 10 years the board had left, “all of the operation things to the administration team.” She stated the board got a “30,000 foot view of everything quality,” to try to steer the direction without, “being in the middle of day to day stuff.” She added that the board designated the CEO as the person responsible for all of the, “operational stuff.” She stated the board, “has been so heavily focused on finance we have run out of time to do everything else,” and she stated that as the president of the board, she did not know that many departments had not reported quality data for most of [2024]. On 05/15/2025 at 11:13 AM the Board President reviewed the document titled, “Quality Summary” with the surveyor which included a review of the following data: -No Quality information was reported for Med-Surg for Quarter #3 2023, Quarter #1 2024, Quarter #3 2024, Quarter #4 2024, & Quarter #1 2025 -No Quality information was reported for the Lab for Quarter #3 2024, Quarter #4 2024 -No Quality information was reported for Housekeeping for Quarter #1 2025 -No Quality information was reported for the Emergency Room (“ER”) also known as the Emergency Department (“ED”) for Quarter #1 2024, Quarter #2 2024 -No Quality information was reported for Rehab for Quarter #3 2024, -No Quality information was reported for Dietary for Quarter #4 2024, & Quarter #1 2025 -No Quality information was reported for the Operating Room for Quarter #1 2024, Quarter #2 2024, Quarter #3 2024, Quarter #4 2024, & Quarter #1 2025 -Quality information was blank for the Pharmacy or Quarter #1 2024, Quarter #2 2024, Quarter #3 2024, & Quarter #4 2024 -No Quality information was reported for Cardiopulmonary for Quarter #2 2024, Quarter #3 2024, Quarter #4 2024, & Quarter #1 2025 Following the review, the Board President stated she was not aware that quality data was not reported by these departments in the above quarters. The Board President stated the board was not aware of the missing quality data either.”

“COMP ASSESSMENT, CARE PLAN & DISCHARGE CFR(s): §485.645(d)(5) Comprehensive assessment, comprehensive care plan, and discharge planning (§483.20(b), and §483.21(b) and (c)(2) of this chapter), except that the CAH is not required to use the resident assessment instrument (RAI) specified by the State that is required under §483.20(b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in §413.343(b) of this chapter). “ §483.20(b) Comprehensive assessments- (1) Resident assessment instrument. A facility must make a comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information. (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychosocial well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnoses and health conditions. (xi) Dental and nutritional status. (xii) Skin condition. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. (2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2) (i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition. (For purposes of this section, “readmission” means a return to the facility following a temporary absence for hospitalization or for therapeutic leave.) (ii) Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition. (For purposes of this section, a “significant change” means a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status, and requires interdisciplinary review or revision of the care plan, or both.) (iii) Not less often than once every 12 months. “ §483.21(b) Comprehensive care plans. (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25, or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25, or §483.40 but are not provided due to the resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (i) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (ii) In consultation with the resident and the resident’s representative(s)- (A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident’s representative(s). An explanation must be included in a resident’s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident’s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident’s needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. (3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. (ii) Be provided by qualified persons in accordance with each resident’s written plan of care. (iii) Be culturally-competent and trauma-informed. “ §483.21(c)(2) Discharge summary. When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident’s stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident’s status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident’s representative. (iii) Reconciliation of all pre-discharge medications with the resident’s post-discharge medications (both prescribed and over-the-counter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident’s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident’s follow up care and any post-discharge medical and non-medical services. This Standard is not met as evidenced by: 50294 Based on document review and interview, the hospital failed to ensure that care plans were completed for one (1) out of ten (10) patient records reviewed (Patient #2). Findings: The hospital’s policy titled “Swing Bed Comprehensive Care Plan,” revised on 11/07/2024, states in part, “...A comprehensive care plan will be developed within 72 hours (3 business days) of completion of the comprehensive assessment...” During a clinical record review on 05/14/2025 at 12:11 PM, Patient #2’s medical record was reviewed and revealed that no care plan was completed. The Case/Utilization Review Manager confirmed these findings at this time. Based on document review and interview, the hospital failed to ensure Resident Assessment Instruments (“RAI”) were completed for two (2) out of ten (10) patient records reviewed (Patient #1 and Patient #2). Findings: The hospital’s policy titled, “Swing Bed Comprehensive Assessment,” effective 07/15/2020, states in part, “...a comprehensive assessment of a resident’s needs, strength, goals, life history and preferences no later than 5 days after admission or within 72 hours after any significant change in patient’s physical or mental condition...” During a clinical record review on 05/14/2025 at 12:09 PM, Patient #1’s medical record was reviewed and revealed that no RAI was completed. The Case/Utilization Review Manager confirmed these findings at this time. During a clinical record review on 05/14/2025 at 12:12 PM, Patient #2’s medical record was reviewed and revealed that no RAI was completed. The Case/Utilization Review Manager confirmed these findings at this time.”

“GRIEVANCES CFR(s): The hospital must establish a clearly explained procedure for the submission of a patient’s written or verbal grievance to the hospital. This Standard is not met as evidenced by: 46424 Based on document review, observations, and interviews, the hospital failed to demonstrate that it has established a clearly explained procedure for the submission of a patient’s written or verbal grievance to the hospital. Findings: The Patient Rights information provided to patients of the hospital states in part, “I have the right to be informed of the facility’s grievance procedure and also to appeal to an external agency, which is posted.” The Vice President of Corporate Compliance/Risk Management/Quality was interviewed on 5/14/2025 at 3:30 PM and was asked what a patient would receive when asking for the hospital’s grievance procedure. The Vice President of Corporate Compliance/Risk Management/Quality thought it was posted at reception desks. When checking at the Internal Medicine practice reception desk in the hospital and at the desk at the main hospital reception area, she confirmed that this information was not posted. A copy of a “Patient Notice” was found posted outside the door of the Chief Financial Officer (not in a patient care area easily accessible to patients and families) which includes information on how a patient can raise a concern, complaint, or grievance, but this Notice includes information which conflicts with the hospital’s “Patient Grievance Policy.” The undated hospital “Patient Grievance Policy” states in part that a “follow-up letter outlining the findings of the investigation shall be provided to the complainant. This letter is to be prepared and sent as soon as practicable, but in all cases, within 30 days of the completion of the investigation. If additional response time is required, the complainant must be notified by phone of the delay and the circumstances warranting the extension.” The “Patient Notice, “ however, states “You can expect to a reasonable response time, usually 7 days.” The Vice President of Corporate Compliance/Risk Management/Quality confirmed this discrepancy at the time of the observation.”

“GRIEVANCES CFR(s): The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 46424 Based on document review, observations, and interviews, the hospital failed to meet the specified time frames in its grievance process for review of grievances and the provision of responses for five (5) of five (5) patient grievances reviewed (Patients #56 - #60). Findings: The undated hospital “Patient Grievance Policy” states in part that a “follow-up letter outlining the findings of the investigation shall be provided to the complainant. This letter is to be prepared and sent as soon as practicable, but in all cases, within 30 days of the completion of the investigation. If additional response time is required, the complainant must be notified by phone of the delay and the circumstances warranting the extension.” On 5/14/2025 at 3:45 PM, a sample of five (5) patient grievances were reviewed with the Vice President of Corporate Compliance/Risk Management/Quality. All five (5) patients received responses later than 30 days after the grievance was received by the hospital. -A grievance from Patient #56 was received on 1/6/2025, and the hospital sent a response letter to the patient on 2/26/2025. -A grievance from Patient #57 was received on 1/19/2025, and the hospital sent a response letter to the patient on 2/21/2025. -A grievance from Patient #58 was received on 1/19/2025, and the hospital sent a response letter to the patient on 2/26/2025. -A grievance from Patient #59 was received on 5/24/2024, and the hospital sent a response letter to the patient on 7/2/2024. -A grievance from Patient #60 was received on 8/27/2024, and the hospital sent a response letter to the patient on 10/9/2024. The Vice President of Corporate Compliance/Risk Management/Quality confirmed in this interview that all these responses were mailed beyond the 30 days specified in the hospital policy, and none of these patients were contacted to inform them that additional time would be required.”

“Subsistence Needs for Staff and Patients CFR(s): §403.748(b)(1), §418.113(b)(6)(iii), §441.184(b)(1), §460.84(b)(1), §482.15(b)(1), §483.73(b)(1), §483.475(b)(1), §485.542(b)(1), §485.625(b)(1) [(b) Policies and procedures. [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 every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal. This Standard is not met as evidenced by: 51673 Based on observations, and record review, the hospital failed to maintain provision of subsistence needs for staff and patients whether they evacuate or shelter in place for Emergency Preparedness Plan in accordance with 42 CFR 482.15(b)(1) Findings: On 05/12/2025, between 11:00 AM and 5:00 PM, this surveyor, with the VP of Corporate Compliance and Risk Management, and the Infection Preventionist/Emergency Preparedness Coordinator/Employee Health RN present, observed the following: 1. No documentation in the emergency preparedness plan provision of subsistence needs for staff and patients whether they evacuate or shelter in place. 2. No ducumentation in the emergency preparedness plan for food, water, medical and pharmaceutical supplies and how they would get replenished in the event they had to evacuate or shelter in place. 3. No documentation in the emergency preparedness plan for fuel to maintain the generator to run for more then the allotted time of fuel on site. This surveyor confirmed these findings with the VP of Corporate Compliance and Risk Management, and the Infection Preventionist/Emergency Preparedness Coordinator/Employee Health RN at the time of the observation.”

“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: 51673 Based on observations, and record review, the hospital failed to develop and implement emergency preparedness policies for Hospitals at 42 CFR §482.15(b)(2) Policies and procedures. [(2) or (1)] 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. Findings: On 5/12/25, between 11:00 AM and 5:00 PM, this surveyor, with the VP of Corporate Compliance and Risk Management, and the Infection Preventionist/Emergency Preparedness Coordinator/Employee Health RN observed the following: 1. No documentation was provided in the emergency preparedness plan of a policy addressing arrangements with other [facilities] to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. This finding was verified by the VP of Corporate Compliance and Risk Management, and the Infection Preventionist/Emergency Preparedness Coordinator/Employee Health RN at the time of observation.”

“Information on Occupancy/Needs CFR(s): §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: 51673 Based on observations, and record review, the hospital failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years. In accordance with 42 CFR §482.15(c)(7) Findings: On 5/12/2025, between 11:00 AM and 5:00 PM, this surveyor, with the VP of Corporate Compliance and Risk Management, and the Infection Preventionist/Emergency Preparedness Coordinator/Employee Health RN present, observed the following: 1. There was no documentation in the emergency preparedness plan of a policy to provide a means of documenting information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. The surveyor confirmed this finding with the VP of Corporate Compliance and Risk Management, and the Infection Preventionist/Emergency Preparedness Coordinator/Employee Health RN at the time of the record review.”

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 51673 Based on observations, and record review, the hospital failed to maintain a training and testing program for Emergency Preparedness Plan in accordance with 42 CFR 482.15 Findings: On 05/12/2025, between 11:00 AM and 5:00 PM, this surveyor, with the VP of Corporate Compliance and Risk Management, and the Infection Preventionist/Emergency Preparedness Coordinator/Employee Health RN present, observed the following: 1. No documentation was provide in the emergency preparedness plan for a training and testing program for employees. This surveyor confirmed this finding with the VP of Corporate Compliance and Risk Management, and the Infection Preventionist/Emergency Preparedness Coordinator/Employee Health RN at the time of the observation.”

“EP Training Program CFR(s): §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: 51673 Based on observations, and record review, the hospital failed to develop and maintain an Emergency Preparedness Training Program in accordance with 42 CFR §482.15. Findings: On 5/12/2025, between 11:00 AM and 5:00 PM, this surveyor, with the VP of Corporate Compliance and Risk Management, and the Infection Preventionist/Emergency Preparedness Coordinator/Employee Health RN present, observed the following: 1. There was no evidence that the hospital has developed and maintained an Emergency Preparedness Training Program in accordance with 42 CFR §482.15. The surveyor confirmed this finding with the VP of Corporate Compliance and Risk Management, and the Infection Preventionist/Emergency Preparedness Coordinator/Employee Health RN at the time of the record review.”

“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: 50034 Federal Recertification Survey Based on plans review and observation, the hospital failed to maintain penetrations and wall construction requirements of the 2-hour separation walls for inspection per NFPA 101, Life Safety Code, 2012 Edition, Sections 8.2.1.3., and 19.1.3.5. Findings include: During a survey conducted on 05/12/2025 between the hours of 11:00 AM and 5:00 PM, a surveyor with the Contract Engineer did observe the following: 1. The 2-hour separation located on the lower level separating the hospital and the medical office building was penetrated by multiple conduits and piping that was not protected by a firestop system or device in accordance with NFPA 221 (2012 edition), Standard for High Challenge Fire, section 4.9.2 Firestop Systems and Devices Required - Penetrations for cables, cable trays, conduit, pipes, tubes, combustible vents and exhaust vents, wires and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a fire stop system or device. The medical office building side of this barrier does not have appear to have any type of firestopping present. This finding was confirmed at the time of observation by this surveyor and the Contract Engineer.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 39983 Based on observations, the Hospital failed to maintain the Exit Corridor required width in 2 egress corridors, every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency per NFPA 101, Life Safety Code, 2012 Edition, Sections 19.2.1, and 7.1.10.1 Findings: On 05/12/2025 between 11:00 AM and 5:00 PM, Surveyors in the presence of the Maintenance Engineer, Chief Nursing Officer, and Nursing Supervisor, the following were not met: 1. Medical equipment is being stored in the exit access corridor located in the Med Surge Unit in the North Wing. 2. A Soiled Utility cart is being stored in the corridor blocking the corridor exit access door located in the Imaging Unit. Surveyors confirmed these findings with the Maintenance Engineer, Chief Nursing Officer, and Nursing Supervisor at the time of the observation. 50034 Federal Recertification Survey Based on observation and interview, the hospital failed to maintain exit corridor width per NFPA 101, Life Safety Code, 2012 Edition, Section 19.2.2 through 19.2.11, 19.2.1, 7.1.10.1 Findings: On 05/12/2025, between 11:00 AM and 5:00 PM, this surveyor, with the Contract Engineer present, observed the following: 1. The exit access corridor located on the lower level by the cafeteria entrance has 2 hospital beds and several photocopy machines stored in the corridor. The Contract Engineer states: These two hospital beds are broken and are waiting to be repaired.” The Contract Engineer further states: :The beds will be repaired in the corridor.” corridor. 2. The exit access corridor located on the lower level by the vending machine and housekeeping storage has miscellaneous items stored in the corridor. This finding was confirmed by this surveyor and the Contract Engineer at the time of the observation.”

“Patient Sleeping Room Doors CFR(s): NFPA 101 Patient Sleeping Room Doors Locks on patient sleeping room doors are not permitted unless the key-locking device that restricts access from the corridor does not restrict egress from the patient room, or the locking arrangement is permitted for patient clinical, security or safety needs in accordance with 18.2.2.2.5 or 19.2.2.2.5. 18.2.2.2, 19.2.2.2, TIA 12-4 This Standard is not met as evidenced by: 39983 Based on observations, the Critical Access Hospital failed to ensure the means of egress from patient rooms meet the requirements of NFPA 101, Life Safety Code, 2012 edition Security and Safety needs in accordance with 19.2.2.2, 19.2.2.2.5. Findings: On 5/12/25 between 11:00 AM and 4:30 PM, in the presence of the Maintenance Engineer and Nursing Supervisor, the following were not met: 1. The Patient room door located in the Emergency Department called the GYN room has a barrel bolt latch fixed to the door on the outside to lock patents in the room. The door cannot be opened from the inside of the room by anyone if the barrel bolt latch is engaged. Surveyors confirmed these findings with the Maintenance Engineer and Nursing Supervisor at the time of the observation.”

“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: 50034 Federal Recertification Survey Based on observation, the Hospital failed to ensure that 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 of NFPA 101 2012 edition. In 1 of 2 smoke compartments. Findings: During a facility tour on 05/12/2025 between hours of 11:00 AM and 5:00 PM. this surveyor, accompanied by the Contract Engineer, did observe the following: 1. The Steam Room, located on the lower level, has a 90-minute rated door into the corridor that does not have a self-closing device attached to it. 2. The Housekeeping Storage Door, located on the lower level, has a self-closing device that would not close the door and allow it to latch. 3. The Dietary Back Storage room door, located on the lower level, does not close and latch. 4. The Laundry Room door, located on the lower level was found open into the exit access corridor and does not close and latch. 5. The Kitchen Door, located on the lower level, when fully opened gets caught on the floor while closing and stops there. 6. The “old cardiac rehab” room, located on the lower level, does not have a self-closing device attached. 7. The storage area off on the kitchen that has double doors into the egress corridor is propped open by two boxes and cannot close. It also does not have a self-closing device attached. These findings were confirmed by the Contract Engineer at the time of the survey. 51959 Based on observation, the facility failed to ensure in 1 of 2 smoke compartments that 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. 2012 edition, NFPA 101 7.2.1.8.2 . Findings: On 05/12/2025 between hours of 11:00 AM and 5:00 PM, this surveyor accompanied by the Maintenance Engineer, did observe the following: 1. The Soiled Linen Room, located near the Operating Rooms, has a door into the corridor that has a self-closing device that did not allow the door to close and positive latch. 2. The Soiled Linen Room, located in inpatient corridor, has a self-closing device that would not close the door and allow it to positively-latch. These findings were acknowledged by the Maintenance Engineer at the time of the survey.”

“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: 42159 Based on documentation and interview, the hospital failed to provide operational emergency lighting testing in accordance with NFPA 101, Life Safety Code, 2012 edition, sections 19.2.9.1, and 7.9.3. Finding: Documentation review with the Contract Engineer present on 05/12/2025 from 11:00 AM to 5:00 PM identified: 1) There is no monthly and annual testing of the emergency lighting. Documentation was provided for the exit signage, but not for the emergency lighting. An interview with the Contract Engineer revealed that they are not tested because they have a generator. This finding was acknowledged by the Contract Engineer at the time of documentation review on 05/12/2025, and during the exit interview on 05/13/2025.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 39983 Based on observations, the Hospital facility failed to mark the required means of egress with appropriate signage in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, Sections 7.10, and 19.2.10.1. Findings: On 5/12/25 between 11:00 AM and 5:00 PM, surveyors in the presence of the Maintenance Engineer, the following was not met: 1. The exit sign located next to the elevator on the Upper Level at Med Surge entrance points to the elevator as the exit. The elevator shall not be used as an exit in case of a fire. A protected stair exit is located on the other side of the 2-hour fire doors. Surveyors confirmed these findings with the Maintenance Engineer and Nursing Supervisor at the time of the observation.”

“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: 39983 Based on observations, the Hospital facility failed to ensure that hazardous areas are protected by the requirements of NFPA 101 2012 edition by a fire barrier having 1-hour fire resistance rating (with 3/4-hour fire rated self-closing doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. Findings: On 05/12/2025 between hours of 11:00 AM and 5:00 PM, surveyors accompanied by the Maintenance Engineer and Nursing Supervisor, did observe the following: 1. Patient room 201 is being used as a storage room. The door self-closer has been removed. The door shall self-close and positively latch. The space is over 50 square feet. Surveyors confirmed these findings with the Maintenance Engineer and Nursing Supervisor at the time of the observation.”

“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: 42159 Based on observation, document review, and interview, the hospital failed to protect the commercial cooking operations by ensuring the entire exhaust system was inspected for grease buildup by a properly trained, qualified, and certified person in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition Sections 11.4 and 12.1.2.2, as referenced by NFPA 101, Life Safety Code, 2012 edition, Section 19.3.2.5.1, and 9.2.3. This deficient practice could affect the kitchen area of the facility by having a commercial cooking assembly that is excessively laden with flammable grease and not properly in place under the extinguishing system. Finding: Observation, Interview, and Document Review during a facility tour with the Contract Engineer present on 05/12/2025 from 11:00 to 5:00PM identified: 1. The is no decal showing the latest inspection for grease buildup by a properly trained, qualified, and certified person attached to the hood. There was no documentation in the files to show that the entire exhaust system was inspected for grease buildup by a properly trained, qualified, and certified person. This finding was acknowledged by the Contract Engineer at the time of observations and during the exit interview on 05/13/2025. 51959 Based on observation, the hospital failed to provide an appropriate hood system for the Therapy Cooking stove per NFPA 101, Life Safety Code, 2012 Edition, Sections 19.3.2.5. Finding: Based on observation on 05/12/2022 between hours of 11:00 AM and 5:00 PM this surveyor accompanied with the Maintenance Engineer did observe the following: 1. The Stove in the Therapy Kitchen, room 204, did not have the proper fire supression hood system per the code requirements set forth for cooking appliances. Stove was observed to be in working order and powered. This deficient practice could affect the residents, visitors and staff. This finding was acknowledged by the Maintenance Engineer at the time of the observation.”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 50034 Federal Recertification Survey Based on observation, the facility failed to ensure that all areas not continuously occupied has a fire alarm detection device near it per NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition, Section 10.15, as referenced by NFPA 101, Life Safety Code, 2012 Edition, Sections 9.6.1.3, 9.6.1.8.1 (1), and 19.3.4.1. Findings: On 05/12/2025, between 11:00 AM and 5:00 PM, this surveyor with the Contract Engineer present, observed the following: 1. There was no automatic smoke detection device installed adjacent to the fire alarm control unit. This finding was confirmed by the surveyor and the Contract Engineer at the time of the observation.”

“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: 42159 Based on documentation review and interview, the facility failed to ensure that the Smoke Detector Sensitivity Testing was performed by a certified Fire Alarm Inspection Company per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, Sections 14.4.2.2, and 14.4.5.3 as referenced by NFPA 101, Life Safety Code, 2012 Edition, Sections 19.3.4, and 9.6.1.5. Finding: On 05/12/2025, between 11:00 AM and 5:00 PM, a surveyor with the Contract Engineer present, observed the following: 1. Upon documentation review of the annual fire alarm inspection report dated 11/01/2024 by Maine Fire Protection Systems, there is no mention of the smoke detector sensitivity testing in this report. I requested the sensitivity report that may be listed in other documentation, and I was told by the Contract Engineer that this is all we have. I explained what the test is and he shrugged and said that this is all we have. No documentation of the sensitivity test was provided. The surveyor confirmed this finding with the Contract Engineer at the time of the observation, and at the exit interview.”

“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: 42159 Based on observation and record review, critical access hospital failed to ensure that 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 sections 13.4.4.2.2.2, and 13.4.4.2.9 as referenced by NFPA 101, Life Safety Code, 2012 Edition, Sections 9.7.1, and 19.3.5.1. Findings: On 05/12/2025, this surveyor, observed the following findings with the Contract Engineer present. 1. Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested. According to the documentation on the riser, the full-flow trip test was last conducted 02/13/2018, making it due in 2021. 2. Dry pipe systems shall be tested once every 3 years for air leakage. There was no documentation provided regarding the 3-year air leakage test. This surveyor confirmed these findings with the Contract Engineer at the time of the documentation review. 50034 Federal Recertification Survey Based on observations, the hospital failed to ensure that Sprinkler System was inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 edition, section 5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). Findings: During a facility tour on 05/12/2025 between the hours of 11:00 AM and 5:00 PM, this surveyor with the Contract Engineer present, observed the following on the lower level: 1. A sprinkler head located in the laundry room is loaded with foreign material. 2. In the Dietary Directors office, a suspended ceiling is obstructing the sprinkler head located directly above it, leaving the room without sprinkler coverage. 3. In the Human Resource storage room, a sprinkler head is missing an escutcheon ring. These findings were confirmed by the surveyor and Contract Engineer at the time of observation.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 50034 Federal Recertification Survey Based on observation, the hospital failed to install portable fire extinguishers where they are readily accessible and immediately available in the event of fire in accordance with NFPA 10, Standard for Portable Fire Extinguishers, 2010 edition, Section 10.6.1.3 as referenced by NFPA 101, Life Safety Code, 2012 edition Sections 9.7.4.1, and 19.3.5.12. Findings: During a facility tour on 05/12/2025 between the hours of 11:00 AM and 5:00 PM, this surveyor and the Contract Engineer observed the following: 1. The K class fire extinguisher located in the kitchen has cases of soda stored in front of it making it not readily accessible. This finding was confirmed by the surveyor and Contract Engineer at the time of observation.”

“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: 39983 Based on observations, the Hospital facility failed to maintain the corridor doors, so they close and positively latch per NFPA 101, Life Safety Code, 2012 Edition, Sections 19.3.6.3, and 19.3.6.3.5. Findings: On 05/12/2025, between 11:00 AM and 5:00 PM, surveyors, with the Maintenance Engineer and Nursing Supervisor present, observed the following: 1. Patient room 203 door did not latch when attempted, door was opened and closed 5 times. Surveyors confirmed these findings with the Maintenance Engineer and Nursing Supervisor at the time of the observation. 50034 Federal Recertification Survey Based on observation, the hospital failed to maintain the corridor door from closing and positively latching per NFPA 101, Life Safety Code, 2012 Edition, Sections 19.3.6.3, 19.3.6.3.5 Findings: On 05/12/2025, between 11:00 AM and 5:00 PM, this surveyor, with the Contract Engineer present, observed the following on the lower level: 1. The housekeeping closet located near the shredder has no latching mechanism attached. 2. The shredder door located near the housekeeping closet has no latching mechanism attached. 3. The room identified as “Jackie’s Closet” has no latching mechanism attached. 4. The cafeteria door is held open by an automated release and has a deadbolt with key mechanism on the exterior and the interior is a flip type device. These findings were verified by the surveyor and Contract Engineer at the time of the observation.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 42159 Based on observation, records review, and interview, the facility failed to test all fire, smoke, and combination fire and smoke dampers in accordance with the NFPA Life Safety Code, 2012 Edition, Sections 9.2.1, and 19.5.2.1. Also reference NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 edition, Section 5.4.8., NFPA Standard NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 edition, Section 19.4, and NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protectives, 2010 edition, Section 6.5. Finding: An interview and documentation review, on 05/12/2025 between 11:00 AM and 5:00 PM with the Contract Engineer present: 1. Records review of the facility’s fire damper testing revealed the facility failed to provide current documentation for the testing and inspection of fire, smoke, and combination fire/ smoke dampers within one (1) year of installation and every six (6) years thereafter. The interview with the contract engineer revealed that they have no documentation since they were last done in September of 2018 by Loggans Sheet Metal, making them due again in 2024. The finding was acknowledged by the Contract Engineer at the time of documentation review and the exit interview on 05/13/2025..”

“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: 42159 Based on documentation review, and interview, the Critical Access Hospital failed to provide documentation that fire drills are conducted quarterly on each shift to familiarize personnel with the signals and emergency actions required under varied conditions per NFPA 101, Life Safety Code, 2012 edition, section 19.7.1.6. Finding: On 05/12/2025, between 11:00 AM and 5:00 PM, a surveyor, Contract Engineer present, observed the following: 1. The fire drill documentation in the fire drill binder was dated: 04/15/2025 at 11:30 in the OR 01/21/2025 at 13:52 med/surge 11/20/2024 at 11:30 Primary Care 06/19/2024 at 14:40 White Birch-off site business building 04/23/2024 at 11:30 White Birch Medical Building off site 02/02/2024 at 10:35 in the kitchen 01/31/2024 unknown details as the documentation was not filled out. I asked the Contract Engineer for more documentation as these are incomplete. He said that if they are not in the binder, then that’s all he has. Interview with the Infection Prevention, Emergency Preparedness, and Employee Health Director during the exit interview revealed that there should be more, but they are not in the binder. Interview also revealed that there are two shifts, and the hours are 0700-1900, and 1900-0700. There was no documented drills from the night shift in the binder for review. The White Birch drills are for the detached medical building on campus, and not part of the hospital occupancy. The Contract Engineer acknowledged this finding at the time of the documentation review and during the exit interview on 05/13/2025.”

“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: 39983 Based on observations, the Hospital Facility failed to ensure the High-Pressure Decorative Laminate, (HPDL) -faced doors, flush wood doors, and stile and rail wood doors with fire ratings greater than 1/3 hour shall not have clearances greater than 1/8 in. between the door and frame, regardless of the door frame construction, and the meeting stiles of paired doors. NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 edition, Section 6.3.1.7. Findings: On 5/12/25 between 11:00 AM and 4:30 PM, Surveyors in the presence of the Maintenance Engineer and Nursing Supervisor, the following was not met: 1. The 2-hour HPDL fire doors entering Med Surge unit from the corridor have a vertical clearance between the 2 door leaves greater than 1/8”. This was measured at 3/8” clearance by surveyors. Surveyors confirmed these findings with the Maintenance Engineer and Nursing Supervisor at the time of the observation. 42159 Based on interview and documentation review, the long-term care facility failed to conduct an annual fire door inspection that ensures that all fire rated doors and hardware are inspected, tested, and maintained by individuals performing the door inspections that possess knowledge, training or experience that demonstrates ability in accordance with NFPA 80, Standard for Fire Door and Other Opening Protectives, 2010 edition Section 5.2 as referenced by NFPA 101, Life Safety Code, 2012 Edition, Sections 19.7.6, and 8.3.3.1 Finding: Documentation review and interview with the Contract Engineer present on 05/12/2025, between 11:00 AM and 5:00 PM identified: 1. The facility had no documentation that the doors had been inspected by a trained employee or a qualified outside vendor in the last year. The most recent annual fire door inspection report provided was done by NFS in May of 2021. Upon further request for a more recent report from the Contract Engineer, he told me that this was the last time the fire doors were inspected and there is no more current paperwork. The Contract Engineer acknowledged this finding at the time of the documentation review and during the exit interview on 05/13/2025.”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 50034 Federal Recertification Survey Based on observations, the hospital failed to comply with the 2012 Life Safety Code Section 19.7.8 Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). Findings: During a facility tour on 05/12/2025 between the hours of 11:00 AM and 5:00 PM, this surveyor along with the Contract Engineer did observe the following: 1. A personal portable heating device was located in the oncology reception area that did not have any anti-tip protection. This device was removed at the time of the survey by oncology staff. 2. A personal portable heating device was located in the office labeled Sandra Bafara that did not have any anti-tip protection. This finding was was confirmed by this surveyor and the Contract Engineer at the time of survey.”

“Gas and Vacuum Piped Systems - Warning System CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Warning Systems All master, area, and local alarm systems used for medical gas and vacuum systems comply with appropriate Category warning system requirements, as applicable. 5.1.9, 5.2.9, 5.3.6.2.2 (NFPA 99) This Standard is not met as evidenced by: 42159 Based on observation, document review, and interview, the hospital failed to install all master, area, and local alarm systems used for medical gas and vacuum systems comply with appropriate category warning system requirements in accordance with NFPA 99, Healthcare Facilities Code, 2012 edition, Sections 5.1.9.2.4., and 5.1.9.5.2 Findings: Documentation Review of the Medical Gas and Vacuum systems inspection report by Acute Medical Gas dated 11/21/2024, during a facility tour with the Contract Engineer present on 05/12/2025 from 11:00 to 5:00PM identified: 1. The CO alarm only initiates at the Plant Operations Panel. The master alarm shall indicate at least one signal from the source equipment to indicate a problem. 2. There are no secondary alarm points located on either master alarm panel. An alarm indication when or just before changeover to the secondary supply system shall be installed. The Contract Engineer was aware of the deficiencies annotated in the report and I was told that nothing has been fixed yet because the facility is under a construction project and the medical gas is part of the project. These deficiencies were annotated on the AMG report from 2023 as well. These findings was acknowledged by the Contract Engineer at the time of observations and during the exit interview on 05/13/2025.”

“Gas and Vacuum Piped Systems - Central Supply CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Central Supply System Operations Adaptors or conversion fittings are prohibited. Cylinders are handled in accordance with 11.6.2. Only cylinders, reusable shipping containers, and their accessories are stored in rooms containing central supply systems or cylinders. No flammable materials are stored with cylinders. Cryogenic liquid storage units intended to supply the facility are not used to transfill. Cylinders are kept away from sources of heat. Valve protection caps are secured in place, if supplied, unless cylinder is in use. Cylinders are not stored in tightly closed spaces. Cylinders in use and storage are prevented from exceeding 130 degrees Fahrenheit, and nitrous oxide and carbon dioxide cylinders are prevented from reaching temperatures lower than manufacture recommendations or 20 degrees Fahrenheit. Full or empty cylinders, when not connected, are stored in locations complying with 5.1.3.3.2 through 5.1.3.3.3, and are not stored in enclosures containing motor-driven machinery, unless for instrument air reserve headers. 5.1.3.2, 5.1.3.3.17, 5.1.3.3.1.8, 5.1.3.3.4, 5.2.3.2, 5.2.3.3, 5.3.6.20.4, 5.6.20.5, 5.3.6.20.7, 5.3.6.20.8, 5.3.6.20.9 (NFPA 99) This Standard is not met as evidenced by: 42159 Based on observation, document review, and interview, the hospital failed to install all master, area, and local alarm systems used for medical gas and vacuum systems comply with appropriate category warning system requirements in accordance with NFPA 99, Healthcare Facilities Code, 2012 edition, Sections 5.1.3.2, 5.1.3.3, 5.1.3.5, 5.1.4.8.3, and 5.1.8.2.1, Findings: Documentation Review of the Medical Gas and Vacuum systems inspection report by Acute Medical Gas dated 11/21/2024, during a facility tour with the Contract Engineer present on 05/12/2025 from 11:00 to 5:00PM identified: 1. On the Oxygen B-1 system, the pressure and vacuum indicators shall be readable from a standing location. The main line pressure indicator is located within a confined space and is not readable from a standing location. 2. On the NOM-1 system there is only one final line regulator and there is no check valve. All positive pressure supply systems shall be provided with duplex line pressure regulators piped in parallel with isolation valves on the source side of the regulator, and the patient side of the regulator. 3. On the NOM-1 system the manifold relief vents are vented into the manifold room and not outside of the building. 4. On the NOM-1 system, there is no pressure relief valve between the final line regulator and the source valve. 5. On the NOM-1 system, the manifolds shall have a local signal that visibly indicated the operating status of the equipment. There are no local signals on the manifold system. 6. On the NOM-1 system, the manifold on the central supply system does not appear to have a check valve on the header. 7. On the NOM-1 system, the manifolds shall consist of two equal headers with the headers connected to the final line pressure system in such a manner that either header can supply the system. The system is currently set up as a 1X1 configuration, and not a 2X2 configuration. 8. The NIM-1 system is just one nitrogen tank with a duplex regulator attached to the tank, that is not monitored except for pressure. This doesn’t meet the requirements of Category 1 Central Supply Systems. 9. In the OXB-1 system, there are not guard posts or another approved means to protect the equipment from vehicular damage. The fencing installed does not provide vehicular protection. 10. In the LMC-1 system, there is combustible storage in the same rooms as the gas cylinders. Only gas cylinders, reusable shipping containers and their accessories shall be permitted to be stored in these areas. The cardboard boxes are not allowed. 11. The LMC-1 door to the manifold room is not lockable. The locations for central supply systems shall be secured with lockable doors or gates. 12. Waste Anesthetic Gas Disposal, (WAGD), networks shall provide an inlet in all locations where nitrous oxide or halogenated gas is administered. Neither of the two Operating Rooms have inlets, to correspond with the outlets. Zone 02-03, and 02-04. 13. In zone 02-02, the medical air outlet leaks at the backbody. 14. In Zone 02-04A, the medical air outlet leaks when it is in use. 15. in Zone 02-06, the first oxygen outlet constantly leaks, whether in use or not. 16. There was no zone valve gauge located on the patient side of the zone valve in 02-04A Med Surge. 17. There was no zone valve gauge located on the patient side of the zone valve in 02-05 Med Surge. 18. There was no zone valve gauge located on the patient side of the zone valve in 02-06 Med Surge. 19. There was no zone valve gauge located on the patient side of the zone valve in 02-07 Med Surge. 20. There was no zone valve gauge located on the patient side of the zone valve in 02-09 Anesthesia. The Contract Engineer was aware of the deficiencies annotated in the report and I was told that nothing has been fixed yet because the facility is under a construction project and the medical gas is part of the project. These deficiencies were annotated on the AMG report from 2023 as well. These findings were acknowledged by the Contract Engineer at the time of observations and during the exit interview on 05/13/2025.”

“Gas and Vacuum Piped Systems - Information an CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Information and Warning Signs Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (Table 5.1.11), and operating pressure if other than standard. Labels are at intervals not more than 20 feet, are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency. 5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99) This Standard is not met as evidenced by: 42159 Based on document review, and interview, the hospital failed to identify the station outlets in accordance with NFPA 99, Healthcare Facilities Code, 2012 edition, Sections 5.1.5.5, and 5.1.11.3 Finding: Documentation Review of the Medical Gas and Vacuum systems inspection report by Acute Medical Gas dated 11/21/2024, during a facility tour with the Contract Engineer present on 05/12/2025 from 11:00 to 5:00PM identified: 1. The outlet in Zone 02-07 is missing the finished identification faceplate. The Contract Engineer was aware of the deficiency annotated in the report and I was told that nothing has been fixed yet because the facility is under a construction project and the medical gas is part of the project. This deficiency was annotated on the AMG report from 2023 as well. This finding was acknowledged by the Contract Engineer at the time of observations and during the exit interview on 05/13/2025.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 50034 Federal Recertification Survey Based on observation, the hospital failed to comply with the 2012 Life Safety Code Section 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2011 NFPA 70 225.19 Findings: During a survey conducted on 05/12/2025 between the hours of 11:00 AM and 5:00 PM, this surveyor and the Contract Engineer observed the following: 1. The electrical panels located in the kitchen have 3 chairs and a food cart stored up against them. This finding was confirmed by the surveyor and the Contract Engineer at the time of observation. 51959 Based on observations, the facility failed to meet the requirements of NFPA 70, National Electrical Code, 2011 edition, Section 314.25, 110.7 as referenced by NFPA 99, Healthcare Facilities Code, 2012 edition, section 6.3.2.1. Findings: On May 12, 2025, between 11:00 AM and 5:00 PM, this surveyor, with the Maintenance Engineer, and Nurse Supervisor, observed the following: 1. Exposed wiring hanging from the ceiling of the Chemistry Lab. 2. Electrical outlet pulled out from the wall in the patient registration office. These findings were acknowledged by the Maintenance Engineer at the time of observation.”

“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: 42159 Based on observation, and interview, and generator inspection documentation review during the facility tour, the Critical Access Hospital failed to maintain the Essential Electric System Generator per NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, sections 8.3.7., 8.3.8, and 8.4.1, and NFPA 99, Healthcare Facilities Code, 2012 edition, section 6.4.4.1.1.3.This deficient practice could affect the patients/residents, visitors, and members of facility staff in this location. Findings: Review of documentation and interview with the Contract Engineer present on 05/12/2025 between 11:00 AM and 5:00 PM identified the following deficiencies: 1) Emergency Power Supply Systems, including all appurtenant components, shall be inspected weekly. The only documentation provided was the monthly load test. During an interview with the Contract Engineer, he stated that the generator is monitored by Omnicare, but it is not inspected weekly in person. Documentation from the CMS site regarding generator inspection requirements was provided to the Contract Engineer at the exit interview. 2) No documentation showing an annual fuel quality test was provided on the generator testing and maintenance documentation. A fuel quality test shall be performed at least annually using appropriate ASTM standards or the manufacturer’s recommendations. The Contract Engineer acknowledged these findings at the time of documentation review on 05/12/2025 and at the exit interview on 05/13/2025.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 39983 Based on observations, the Hospital facility failed to ensure that power strips are not used for non-PCREE (Patient-care-related electrical equipment) and that power strips are not used as a substitute for fixed wiring in accordance with NFPA 99, Healthcare Facilities Code, 2012 edition, Chapter 10, NFPA 70, National Electrical Code, 2010, Section 400.8(1) Findings: On 05/12/2025, between 11:00 AM and 5:00 PM, surveyors with the Maintenance Engineer, Nursing Supervisor, and Chief Nursing Officer present observed the following: 1. In patient room 214 in the Med Surge Unit, an orange extension cord is being used to power a negative pressure unit as a permanent power source. 2. An orange extension cord is being used as a permanent power supply for an appliance in the O.R. Unit staff lounge. 3. An extension cord power strip is being used as a permanent power supply for a microwave oven, toaster, and coffee maker in the Diagnostic Imaging Unit in the closet by C.T. Surveyors confirmed these findings with the Maintenance Engineer, Nursing Supervisor, and Chief Nursing Officer at the time of the observation.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 51959 Based on observation, the health care facility failed to ensure that Gas Equipment - Cylinder and Container Storage rooms are equipped with precautionary signage in accordance with NFPA 99, Healthcare Facilities Code, 2012 Edition, Section 11.3.4. Finding: On 5/12/2025, between 1:00 PM and 4:00 PM, a surveyor, with the Maintenance Engineer present, observed the following: 1. The storage room (210) in the inpatient wing was found being used for oxygen cylinder storage with less than 300 cubic feet and was not marked with a precautionary sign, readable from a distance of 5 feet stating “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING” The surveyor confirmed this finding with the Maintenance Engineer at the time of the observation.”

“Gas Equipment - Precautions for Handling Oxyg CFR(s): NFPA 101 Gas Equipment - Precautions for Handling Oxygen Cylinders and Manifolds Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99) 11.6.2 (NFPA 99) This Standard is not met as evidenced by: 50034 Federal Recertification Survey Based on observation, the hospital failed to comply with 2012 NFPA 101 19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing. 2012 NFPA 99 11.3.2.6 Cylinder or container restraints shall comply with 11.6.2.3. 11.6.2.3 Findings: On 05/12/2025 between the hours of 11:00 AM and 5:00 PM, surveyors and the Contract Engineer observed the following: 1. In the Oxygen Storage room, located on the lower level near the cafeteria, a K size oxygen tank is not properly chained or supported in a cylinder stand or cart. This finding was confirmed by the surveyor and Contract Engineer at the time of the survey.”

“Features of Fire Protection - Fire Loss Preve CFR(s): NFPA 101 Features of Fire Protection - Fire Loss Prevention in Operating Rooms Periodic evaluations are made of hazards that could be encountered during surgical procedures, and fire prevention procedures are established. When flammable germicides or antiseptics are employed during surgeries utilizing electrosurgery, cautery or lasers: * packaging is non-flammable * applicators are in unit doses * Preoperative “time-out” is conducted prior the initiation of any surgical procedure to verify: o application site is dry prior to draping and use of surgical equipment o pooling of solution has not occurred or has been corrected o solution-soaked materials have been removed from the OR prior to draping and use of surgical devices o policies and procedures are established outlining safety precautions related to the use of flammable germicide or antiseptic use Procedures are established for operating room emergencies including alarm activation, evacuation, equipment shutdown, and control operations. Emergency procedures include the control of chemical spills, and extinguishment of drapery, clothing and equipment fires. Training is provided to new OR personnel (including surgeons), continuing education is provided, incidents are reviewed monthly, and procedures are reviewed annually. 15.13 (NFPA 99) This Standard is not met as evidenced by: 42159 Based on interview and documentation review the Critical Access hospital failed to document Fire Loss Prevention procedures in operating rooms in accordance with NFPA 99, Healthcare Facilities Code, 2012 Edition, Section 15.13. Findings On 05/12/2025 from 11:00 and 5:00 PM with the Contract Engineer present identified the following: 1. A periodically reviewed hazard assessment was not provided that documents hazards including, but not limited to environmental, equipment, and electrical hazards. 2. Documented procedures for operating room/surgical suite emergencies were not available that include but are not limited to chemical spills, extinguishing drapery, clothing, or equipment fires alarm actuation, evacuation, and equipment shutdown procedures and provisions. 3. Documented procedures for controlling and preventing emergencies that could occur in the operating room, including specific detailed plans for control operations by an emergency control group within the organization or a public fire department were not provided. 4. No documentation of employee training on emergency operating room specific procedures and hazards was provided. The MRH department specific fire plan for the operating room did not give adequate details and explanations for these required topics. This surveyor confirmed these findings with the Contract Engineer at the time of the documentation review.”

“NOTICE OF RIGHTS CFR(s): A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under state law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible This Standard is not met as evidenced by: 09447 Based on document reviews and interviews, the facility failed to ensure that each patient was informed, or when appropriate, the patient’s representative (as allowed under state law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible in ten (10) of ten (10) patient records. Records #1- #10 Finding: On 10/22/2024 at approximately 12:00 PM, a review of ten (10) patient medical records was conducted. The ten (10) records contained no documentation that the patient had received their Patient Rights information. On 10/22/2024 at 1:55 PM, during an interview with the Vice President of Compliance and Risk, the above finding was verified. She stated that the registration personnel, the ones responsible for giving the Patient Rights pamphlet to patients, were not documenting in the patient’s medical record that the patients had received the Patient Rights pamphlet.”

“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: 45336 Based on review of documentation the facility failed to ensure patients presenting to the Emergency Department (ED) recieved an appropriate medical screening exam, in 1 of 21 sampled patients (Patient #1) (A-2406). The facility failed to provide evidence a Medical Screening Exam was completed for Patient #1 who was transported to the hospital by the police and presented to the rear entrance of the emergency department on 6/22/2024. Cross reference: §489.24(a); §489.24(c) Appropriate Medical Screening Examination”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 45336 Based on review of documentation and interviews, it was determined the facility failed to provided Patient #1, an appropriate medical screening exam at the facility’s Emergency Department (ED) on 06/22/2024. Findings: Facility policy titled “EMTALA” last revised 01/24/2024, states in part: “2. All persons presenting to the Hospital main campus requesting emergency care must be accepted and evaluated by a qualified medical provider, regardless of ability to pay.” “3. In the absence of an actual request for services, if a ‘prudent layperson’ observer would believe, based on the individual’s appearance or behavior, that the individual needs an examination or treatment for a medical condition, EMTALA still applies and the person must be accepted and evaluated for treatment.” “DEFINITIONS: Hospital Property: The entire main Millinocket Regional Hospital (Hospital) campus including the parking lot, sidewalk, driveway, Hospital departments, Hospital clinics, and any building owned by the Hospital that is within 250 yards of the Hospital.” Review of facility documentation dated 06/22/2024 indicated that the facility had received a call from a police officer about Patient #1 who was “in a manic state” and “heightened state of arousal” who had been speeding. The document further indicated that Patient #1 was recently discharged from another hospital for “similar behavior” and has a “history of “Bipolar II/Schizophrenia and has not been compliant with [Patient #1’s] medications for a while.” The document further revealed (name of police officer) “arrived at the rear entrance of the emergency department and asked if we were able to receive (Patient #1).” Staff Member #1, a nurse, consulted with Staff Member #2, a provider, to inquire about the possibility of the police department to exercise their ability to direct transport this person to a more appropriate facility that could meet [Patient #1’s] needs. An interview with Staff Member #3, CNO revealed Staff Member #1 did suggest that Police Officer take Patient #1 to another facility. Patient #1 was transported by police to another hospital and #1 did not receive a medical screening evaluation.”