Chippewa County Hospital

“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: 48583 Based on observation, interview and document review, the critical access hospital (CAH) failed to ensure 2 of 3 negative pressure rooms (for airborne isolation- a room which had a ventilation system that generated a negative pressure to allow air flow into the isolation room, while preventing contaminated air from escaping the isolation room), (room 103 on the medical/surgical wing and the isolation/pediatric room on the operating room wing) were properly maintained and monitored. Findings include: On 12/10/24 at 2:38 p.m., a tour of the nursing unit was completed with the maintenance manager (MM). During the tour, patient room 103 and the isolation/pediatric room were observed to have the capabilities of being converted to a negative pressure room. MM confirmed room 103 and the isolation/pediatric room were the CAH’s negative pressure rooms. MM had nursing staff demonstrate the negative pressure in room 103 was activated by closing the door and setting negative pressure on a panel on the wall to the left of the door. The panel indicated the pressure fluctuated between 0.1450 and 0.0140. The negative pressure set point of 0.0060 was not reached. The indicator light did not activate red or green to indicate if the negative pressure was working or had been interrupted. MM had nursing staff demonstrate the negative pressure in the isolation/pediatric room on the operating room wing was activated by closing the door and setting the negative pressure panel on the wall to the left of the door. The panel indicated the pressure fluctuated between 0.0080 and 0.1050. The negative pressure set point of 0.0060 was not reached. The indicator light did not activate red or green to indicate if the negative pressure was working or had been interrupted. During an interview on 12/10/24 at 3:12 p.m., MM confirmed the above findings and indicated the negative pressure rooms had faulted in the past due to the belts on the roof being worn out. MM indicated the belts needed to be replaced. During an interview on 12/10/24 at 3:14 p.m., the safety officer (SO) identified the negative pressure rooms were to be tested monthly. SO stated he thought they were being tested monthly by the managers responsible for the medical/surgical and operating room wing. SO indicated. “I should probably take the monthly negative pressure room checks off the managers plates as I have to check the ones in the clinic as well.” SO stated he did not have any monthly logs documentation showing the negative pressure rooms had been tested. During an interview on 12/11/24 at 11:56 a.m., director of nursing (DON) indicated she was not aware the negative pressure rooms were not working properly. DON stated she was not aware she was responsible to perform monthly checks on the medical/surgical wing. During an interview on 12/11/24, 4:30 p.m., chief executive officer (CEO) acknowledged the negative pressure rooms were not working and there were no logs identifying the negative pressure rooms were being tested monthly. Email received from DON on 12/11/24 at 12:21 p.m., indicated the facility did not have a policy specific to negative pressure rooms. Review of the facility instructions titled To Set Low Pressure Alarm, undated, indicated the negative pressure set point was to be at 0.0060.”

“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: 34083 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: K321, K353, K712 and K901 for additional information.”

“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: 27955 Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure Patient Rights and Dietary Services were evaluated through the quality assurance program. Findings include: During an interview on 12/11/24 at 10:40 a.m., with health information management (HIM) director stated there was no formal Quality Assurance and Performance Improvement (QAPI) projects related to patient rights. During an interview on 12/11/24 at 2:48 p.m., the Cief Nursing Officer (CNO) confirmed she had not been able to find anyone in the hospital who was aware of QAPI projects regarding patient rights. 48583 During a follow-up interview on 12/10/24 at 3:38 p.m., CNO identified she was aware the facility was expected to review and develop a QAPI project for the dietary department however confirmed the facility had no current QAPI projects for the dietary department. During an interview on 12/11/24 at 4:30 p.m., chief executive officer (CEO), indicated he understood the QAPI requirements. Review of facility policy titled Organizational Quality Assurance and Performance Improvement, dated pending, the facility will have a comprehensive program and plan that guides all performance improvement activities in accordance with the organization’s mission and vision.”

“FIRE SAFETY A Life Safety Code survey was conducted by the Minnesota Department of Public Safety, State Fire Marshal Division on 12/10/2024. At the time of this survey, CCM Health was found not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR, Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of National Fire Protection Association (NFPA) Standard 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. Chippewa County Montevideo Hospital is a 1-story building with a partial basement. The building was constructed in 2009 and was determined to be of Type I(332) construction. The building is fully sprinklered. The facility has a fire alarm system with smoke detection in the corridors and spaces open to the corridors that is monitored for automatic fire department notification. The facility has a capacity of 25 beds and had a census of 12 at time of the survey. The requirement at 42 CFR, Subpart 483.70(a) is NOT MET as evidenced by:”

“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: 49715 Based on observation and staff interview, the facility failed to maintain hazardous area enclosures per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.1, 19.3.2.1.3, and 19.3.6.3.5. These deficient findings could have a patterned impact on the residents within the facility. Findings include: 1. On 12/10/2024 between 9:00 AM and 12:30 PM, it was revealed by observation that the Oncology Clean Linen Room was being used to store combustible items and did not have a self-closing device on the door. 2. On 12/10/2024 between 9:00 AM and 12:30 PM, it was revealed by observation that Patient Room 112 was being used to store combustible items and did not have a self-closing device on the door. An interview with the Maintenance Manager verified these deficient findings at the time of discovery.”

“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: 49715 Based on observation, a review of available documentation, and staff interview, the facility failed to inspect and maintain the fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, section 9.7.5, and NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, section 5.4.1.4.2. This deficient finding could have a widespread impact on the residents within the facility. Findings include: On 12/10/2024 between 9:00 AM and 12:30 PM, it was revealed by observation that several sprinkler heads were being stored unsecured in the basement sprinkler riser room cabinet. An interview with the Maintenance Manager verified this deficient finding at the time of discovery.”

“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: 49715 Based on a review of available documentation and staff interview, the facility failed to conduct fire drills per NFPA 101 (2012 edition), Life Safety Code section 19.7.1.6. This deficient finding could have a widespread impact on the residents within the facility. Findings include: On 12/10/2024 between 9:00 AM and 12:30 PM, it was revealed by a review of available documentation that the fire drills for the 3rd shift were taking place between 0600 and 0609 hours during each quarterly drill and times were not being varied from drill to drill. An interview with the Maintenance Manager 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 12/10/2024 between 9:00 AM and 12:30 PM, it was revealed by a review of available documentation that the facility could not provide an NFPA 99 Risk Assessment for Chapters 5, 6, 9, 10 and 11 at the time of the survey. An interview with the Maintenance Manager verified this deficient finding at the time of discovery.”