Johnson Memorial Hospital

“COMPLIANCE FED, ST, AND LOCAL LAWS AND REGS CFR(s): The CAH is in compliance with applicable Federal laws and regulations related to the health and safety of patients. This Standard is not met as evidenced by: 48583 Based on observation and interview, the critical access hospital (CAH) failed to ensure signage was posted in all visible areas of the Emergency Department (ED) and at the front clinic entrance identifying a medical doctor was not on duty 24 hours a day/7 day a week. This had the potential to affect all admitted patients and/or those seen in the ED. Findings include: During a tour/interview on 2/25/25 at 2:45 p.m., a tour of the emergency department (ED) was completed with the director of nursing (DON). The ED had three treatment rooms used for ED patients. Treatment room one (closest to the nurse’s station) and treatment room three (closest to the ED entrance) had doors accessing the rooms. Treatment room two was located between treatment room one and treatment room three. Patients could access the ED through the ED entrance (entering through the ambulance garage door and walking approximately 25 feet up a ramp to the facility entrance door) or through the main clinic door (during normal business hours). The only posted notification identifying a medical doctor was not on duty on a 24/7 basis was located outside treatment room one’s door. The notification was typed on an 8 ½ inch by 11-inch sheet of paper and placed into a frame approximately five feet off the floor. The notification would not be seen by patients entering the ED through the ambulance garage and entering treatment room three for services in treatment rooms two or three. In addition, no notification was posted in any ED treatment room. During an observation on 2/26/25 at 10:30 a.m., notification identifying a provider was not on duty on a 24/7 basis was not posted in the main clinic entrance which was an additional entrance for patients seeking services in the ED. In addition, no notification was posted in the only waiting area within the hospital where patients could wait to be seen for medical treatment in the ED. The notification would not be seen by individuals entering the facility through the main clinic door and entering treatment room three for services in treatment room two or three. During an interview on 2/26/25 at 11:30 a.m., DON confirmed the above findings and stated the facility had been working on getting updated notifications, but it had been missed. DON stated it was important to have notifications at all entrances where patients could access ED services as well as posting notifications within each ED treatment room. DON indicated the facility would be working to update notifications promptly. A hospital policy was not obtained.”

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 48583 Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital. Findings include: Please refer to the Life Safety Code inspection tags: K0363, K0372, and K0901.”

“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: 40614 Based on interview and document review, the facility failed to ensure informed consent forms included the signature of the patient or legal guardian for 1 of 8 patients (P21) reviewed for surgical procedures. Findings include: P21’s pre-operative history and physical (H&P) dated 12/6/24 indicated P21 had an intellectual disability, generalized anxiety disorder and epilepsy. Review of guardianship, healthcare agents and power of attorney/conservatorship indicated none was on file in the medical record. Review of Health Care Directive, scanned to medical record 5/4/18 indicated FM-D was the healthcare agent. P21’s document titled Patient Consent for neck mass excision was signed, dated, and timed by caregiver (C)-B. Registered nurse (RN)-A stated P21 was from a group home and was accompanied by one of the group home workers for his surgery. Review of medical record indicated emergency contact as FM-C who RN-A indicated was not present on site the day of the surgical procedure. RN-A confirmed the emergency contact, guardian or power of attorney should have signed the Patient Consent form versus the group home employee. RN-A added they should have called FM-C or FM-D and got a verbal consent with two witnesses. P21’s Admission assessment and documentation identified family present as other, Caregiver-B. The Consent for Surgical or Invasive Procedure policy dated 2/2025, directed all consents are to be informed consents meaning the practitioner has provided sufficient information in words the patient or their representative can understand to make an informed decision. The “informed consent” must be signed by the patient or their representative the day of the surgery/procedure or in the attending or performing practitioner’s office. The following patients are responsible for their own consents: Adults, 18 years and older, who are not under guardianship or mentally incompetent. On 2/26/25 at 12:50 p.m., the director of nursing confirmed the Patient Consent should have been signed by the patient or a family member for the surgical procedure.”

“DESIGNATION OF QUALIFIED PRACTITIONERS CFR(s): The CAH designates the practitioners who are allowed to perform surgery for CAH patients, in accordance with its approved policies and procedures, and with State scope of practice laws. Surgery is performed only by-- (1) A doctor of medicine or osteopathy, including an osteopathic practitioner recognized under section 1101(a)(7) of the Act; (2) A doctor of dental surgery or dental medicine; or (3) A doctor of podiatric medicine. This Standard is not met as evidenced by: 40614 Based on interview and document review, the facility failed to ensure a current roster listing specific to each practitioner’s surgical privileges was available in the surgical suite or where scheduling of surgical procedures is done, and that staff were aware of where these documents were located. Findings include: On interview and tour of the surgical unit 2/24/25 at 2:47 p.m., registered nurse (RN)-B stated she wasn’t aware of a privilege list located in the surgery department or where to find one and would verify with the provider if they are privileged to do the procedure if she had any questions. On interview 2/25/25 at 8:20 a.m., RN-A, also identified as surgery director, was not aware of a privileging list being in the surgery department and stated they take some surgeons for granted that they have the designated surgical procedure privileges. RN-A added they have worked with some of these doctors for 30 years, they have a degree in surgery, and they know what the surgeons can do. RN-A added they do not do any major surgical procedures at the facility. On interview 2/25/25 at 10:46 a.m., RN-C indicated she is not aware of a credentialing list and if she questioned anything she would ask the surgery manager. On interview 2/26/25 at 10:57 a.m., RN-A stated she was able to locate the credentialing lists on the computer and stated there are only three surgeons listed that are still here practicing and some of the newer surgeon’s credentialing lists were not present. RN-A stated she will get this updated and complete education for the surgical staff. On interview 2/26/25 at 10:25 a.m., the director of nursing (DON) and executive assistant (AA)-A also identified as person responsible for credentialing, were not aware of any list of privileges for the surgeons or of any electronic files of privileges. AA-A indicated they have had turnover in the credentialing role over the past year and she recently took over the duties. The DON confirmed a list should be available for surgical staff. A policy and procedure for credentialing was requested. The Rules and Regulations of the Medical Staff was received and included patients may be treated only by providers who have submitted proper applications and have been duly appointment to membership on the medical staff or granted temporary privileges.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (2) Be ongoing and comprehensive. (3) Involve all departments of the CAH and services (including those services furnished under contract or arrangement). This Standard is not met as evidenced by: 48583 Based on interview and record review the Critical Access Hospital (CAH) failed to ensure medical records were evaluated through the quality assessment and performance improvement (QAPI) program. Findings include: During and interview on 2/25/25 at 2:36 p.m., health information management director (HIMD) indicated record keeping was not involved QAPI and she did not report anything formally to QAPI. HIMD further indicated she was unaware of any goals or measurements medical records/record keeping had for QAPI. During an interview on 2/25/25 at 4:01 p.m., director of nursing (DON) indicated she did not put QAPI information together for medical records/record keeping as it was the responsibility of the HIMD. DON further indicated the quality director (QA) was responsible for putting together all departments QAPI information. During a follow-up interview on 2/26/25 at 11:30 p.m., DON stated that medical records/record keeping did not directly report to QAPI. DON stated that the HIMD was responsible for reviewing and auditing medical charts and this information was shared during reviews but was unable to locate the information within the QAPI report. DON agreed HIMD should share medical information more formally as it was scattered throughout QAPI. DON stated this would ensure the goals and measurements are being met. Review of Johnson Memorial Health Services Quality Plan dated 2024, identified the objectives were to promote and maintain high quality and continuity of care. This included the coordination and integration of all quality activities at Johnson Memorial Health Services.”

“ORGAN, TISSUE, & EYE PROCUREMENT CFR(s): Ensure that the CAH works cooperatively with the designated OPO, tissue bank and eye bank in educating staff on donation issues, reviewing death records to improve identification of potential donors, and maintaining potential donors while necessary testing and placement of potential donated organs, tissues, and eyes takes place. §485.643(f) For purpose of these standards, the term “organ” means a human kidney, liver, heart, lung, pancreas, or intestines (or multivisceral organs). This Standard is not met as evidenced by: 48583 Based on interview and document review, the critical access hospital (CAH) failed to have a system to collaborate and communicate with the Organ Procurement Organization (OPO) for 2 of 2 patients (P1 and P5) reviewed to ensure every patient’s death was being reviewed. Findings include: Review of P1 and P5’s electronic medical records (EMR) dated 4/1/24 through 12/31/24, the facility followed the policy and contacted LifeSource within the required one hour for both patients identified on the facilities Hospital Program overview. Review of the facility’s Hospital Program overview dated 4/1/24 through 9/30/24, the facility had two referrals to LifeSource for the facility. Review of the facility’s Lion’s Gift of Sight report dated quarter one 2022 through quarter four 2024, the facility had four potential eye donor, two actual eye donors, four transplant tissue donors, and two late referrals. During an interview on 2/25/25 at 3:55 p.m., director of nursing (DON) stated she receives a quarterly report from LifeSource, reviews the report, which does not contain patient names or medical record numbers and compares it to the death of the patient to verify compliance with staff contacting LifeSource within the one hour time frame; however, if the hospital had a death and LifeSource was not contacted, the patient identification is not on the LifeSource Report. The DON stated she receives Lion’s Gift of Sight report yearly, reviews the report, which does not contain patient names or medical record numbers, for donations or rejections but does not compare the report to any medical records or facility tracking system. In addition, either OPO tracking is not brought forward to QAPI. She stated the hospital did have two eye donations that were not reviewed or brought to the attention of QAPI. During a follow-up interview on 2/26/25 at 11:55 a.m., DON stated she was the only one in charge of the OPO information and again confirmed the reports were not part of QAPI. Facility policy titled Organ and Tissue Donation revised 10/22, did not provide any information related to OPO and QAPI.”

“FIRE SAFETY An annual Life Safety Code survey was conducted by the Minnesota Department of Public Safety, State Fire Marshal Division on 02/26/2025. At the time of this survey, Johnson Memorial Hospital Building 01 was found not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR, Subpart 483.70(a), Life Safety from Fire, and the 2012 edition of National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care Occupancies and the 2012 edition of NFPA 99, Health Care Facilities Code. THE FACILITY’S POC WILL SERVE AS YOUR ALLEGATION OF COMPLIANCE UPON THE DEPARTMENT’S ACCEPTANCE. YOUR SIGNATURE AT THE BOTTOM OF THE FIRST PAGE OF THE CMS-2567 FORM WILL BE USED AS VERIFICATION OF COMPLIANCE. UPON RECEIPT OF AN ACCEPTABLE POC, AN ONSITE REVISIT OF YOUR FACILITY MAY BE CONDUCTED TO VALIDATE THAT SUBSTANTIAL COMPLIANCE WITH THE REGULATIONS HAS BEEN ATTAINED IN ACCORDANCE WITH YOUR VERIFICATION. PLEASE RETURN THE PLAN OF CORRECTION FOR THE FIRE SAFETY DEFICIENCIES (K-TAGS) TO: IF PARTICIPATING IN THE E-POC PROCESS, A PAPER COPY OF THE PLAN OF CORRECTION IS NOT REQUIRED. Healthcare Fire Inspections State Fire Marshal Division 445 Minnesota St., Suite 145 St. Paul, MN 55101-5145, OR By email to: FM.HC.Inspections@state.mn.us THE PLAN OF CORRECTION FOR EACH DEFICIENCY MUST INCLUDE ALL OF THE FOLLOWING INFORMATION: 1. A detailed description of the corrective action taken or planned to correct the deficiency. 2. Address the measures that will be put in place to ensure the deficiency does not reoccur. 3. Indicate how the facility plans to monitor future performance to ensure solutions are sustained. 4. Identify who is responsible for the corrective actions and monitoring of compliance. 5. The actual or proposed date for completion of the remedy. Johnson Memorial Hospital Building 01 is licensed as a Critical Access Hospital and is a 1 story building without basement. The building was constructed at 3 different times. The original building was constructed in 1974 and was determined to be of Type II(111) construction. In 1997 an addition was added that was also determined to be of Type II(111). In 2007 an addition was added to both the northwest and south ends of the facility that were determined to be of Type II(111) construction. The building is protected by a complete fire sprinkler system. The facility has a fire alarm system with smoke detection that is monitored for automatic fire department notification. The facility has a capacity of 15 certified beds and had a census of 1. The requirement at 42 CFR, Subpart 485.623(d) is NOT MET as evidenced by:”

“FIRE SAFETY An annual Life Safety Code survey was conducted by the Minnesota Department of Public Safety, State Fire Marshal Division on 02/26/2025. At the time of this survey, Johnson Memorial Hospital Building 04 was found not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR, Subpart 483.70(a), Life Safety from Fire, and the 2012 edition of National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 18 New Health Care Occupancies and the 2012 edition of NFPA 99, Health Care Facilities Code. THE FACILITY’S POC WILL SERVE AS YOUR ALLEGATION OF COMPLIANCE UPON THE DEPARTMENT’S ACCEPTANCE. YOUR SIGNATURE AT THE BOTTOM OF THE FIRST PAGE OF THE CMS-2567 FORM WILL BE USED AS VERIFICATION OF COMPLIANCE. UPON RECEIPT OF AN ACCEPTABLE POC, AN ONSITE REVISIT OF YOUR FACILITY MAY BE CONDUCTED TO VALIDATE THAT SUBSTANTIAL COMPLIANCE WITH THE REGULATIONS HAS BEEN ATTAINED IN ACCORDANCE WITH YOUR VERIFICATION. PLEASE RETURN THE PLAN OF CORRECTION FOR THE FIRE SAFETY DEFICIENCIES (K-TAGS) TO: IF PARTICIPATING IN THE E-POC PROCESS, A PAPER COPY OF THE PLAN OF CORRECTION IS NOT REQUIRED. Healthcare Fire Inspections State Fire Marshal Division 445 Minnesota St., Suite 145 St. Paul, MN 55101-5145, OR By email to: FM.HC.Inspections@state.mn.us THE PLAN OF CORRECTION FOR EACH DEFICIENCY MUST INCLUDE ALL OF THE FOLLOWING INFORMATION: 1. A detailed description of the corrective action taken or planned to correct the deficiency. 2. Address the measures that will be put in place to ensure the deficiency does not reoccur. 3. Indicate how the facility plans to monitor future performance to ensure solutions are sustained. 4. Identify who is responsible for the corrective actions and monitoring of compliance. 5. The actual or proposed date for completion of the remedy. Johnson Memorial Hospital Building 04 is licensed as a Critical Access Hospital and is a 1 story building without a basement. In January 2019, the Business Office, Waiting Room, Learning Center, Registration, Lobby Vestibule, and Link from the hospital to the nursing home were constructed. Construction type was determined to be Type II (111). The building is protected by a complete fire sprinkler system. The facility has a fire alarm system with smoke detection that is monitored for automatic fire department notification. The facility has a capacity of 15 certified beds and had a census of 1. The requirement at 42 CFR, Subpart 485.623(d) is NOT MET as evidenced by:”

“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: 49715 Based on observation and staff interview, the facility failed to maintain corridor doors per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.6.3 and 19.3.6.3.5. This deficient finding could have an isolated impact on the residents within the facility. Findings include: On 02/26/2025 between 9:30 AM and 12:00 PM , it was revealed by observation that door for the Kitchenette in the patient room area did not latch when closed using the self-closing device. An interview with the Maintenance Director verified this deficient finding at the time of discovery.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 49715 Based on observation and staff interview, the facility failed to maintain smoke barriers per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.7.3, and 8.5.2.1. This deficient finding could have an isolated impact on residents within the facility. Findings include: On 02/26/2025 between 9:30 AM and 12:00 PM, it was revealed by observation that a ceiling tile was missing in the ceiling of the North IT Closet. An interview with the Maintenance Director verified this deficient finding at the time of discovery.”

“Fundamentals - Building System Categories CFR(s): NFPA 101 Fundamentals - Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99) This Standard is not met as evidenced by: 49715 Based on a review of available documentation and staff interview, the facility failed to provide a Risk Assessment per NFPA 99 (2012 edition), Health Care Facilities Code, section 4.2. This deficient finding could have a widespread impact on the residents within the facility. Findings include: On 02/26/2025 between 9:30 AM and 12:00 PM, it was revealed by a review of available documentation that the facility could not provide an NFPA 99 Risk Assessment for Chapters 5 Medical Gases, at the time of the survey. An interview with the Maintenance Director verified this deficient finding at the time of discovery.”

“Fundamentals - Building System Categories CFR(s): NFPA 101 Fundamentals - Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99) This Standard is not met as evidenced by: 49715 Based on a review of available documentation and staff interview, the facility failed to provide a Risk Assessment per NFPA 99 (2012 edition), Health Care Facilities Code, section 4.2. This deficient finding could have a widespread impact on the residents within the facility. Findings include: On 02/26/2025 between 9:30 AM and 12:00 PM, it was revealed by a review of available documentation that the facility could not provide an NFPA 99 Risk Assessment for Chapters 5 Medical Gases, at the time of the survey. An interview with the Maintenance Director verified this deficient finding at the time of discovery.”