Mille Lacs Health System

“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 all departments CAH wide were evaluated through the quality assessment and performance improvement (QAPI) program. Findings include: On 3/25/25, a review of QAPI documents lacked evidence of a QAPI project for discharge planning and telemedicine. During an interview on 3/25/25 at 4:10 p.m., Director of Quality (DQ) indicated there was no QAPI projects for discharge planning and telemedicine. DQ stated there was nothing formal reported to the QAPI committee. The facility policy Quality Assessment and Performance Improvement (QAPI) Program, undated revealed the facility would complete an annual Program Assessment would be completed as part of the QAPI program. The assessment would look at an annual summary of the dimension of care within our services and the evaluation of utilization from the previous year. In addition, the QAPI activities would be integrated across all service areas of their facility.”

“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 5 of 5 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), (acute care rooms 209, 210, 211 and emergency exam rooms 5, 6) were properly maintained and monitored. In addition, the CAH failed to ensure staff received audible notification if negative pressure had been disrupted (thresholds on the air precaution rooms are set manually) in a room. On 8/13/24 at 11:28 a.m., a tour of the nursing unit was completed with director of nursing (DON) and registered nurse (RN)-A. During the tour, patient rooms 209, 210, and 211 were observed to have the capabilities of being converted to a negative pressure room. DON and RN-A confirmed rooms 209, 210, and 211 were the CAH’s negative pressure rooms on the acute care floor. DON and RN-A further confirmed rooms 5 and 6 in the emergency department were negative pressure rooms. During the tour room 211 had a current patient on airborne plus precautions (prevent the spread of germs through air or dust) and negative pressure was being used. During the tour room 211’s door was open approximately 8 to 12 inches and a staff member was present in the room. The negative pressure monitor to the left of the door indicated the negative pressure was working and the screen was green even though the door was open. The DON walked over to the door and closed it. The DON confirmed the door was open and should have been closed at all times. DON also confirmed that the negative pressure panel remained green and did not turn red when the negative pressure was disrupted. DON requested RN-A to review the negative pressure panels to ensure they were working properly. RN-A checked the negative pressure in room 211 and indicated it was activated. RN-A stated the panel will start to flash red if the negative pressure was disrupted. Throughout the tour all additional negative pressure rooms were checked and were working properly. DON confirmed no routine checks were being done on the negative pressure room to ensure each room is working properly. DON further confirmed, no audible alarm would activate to notify staff if negative pressure were disrupted. DON stated if the negative pressure were not working in a room and staff were not notified, this could put all staff and patients at risk for contacting an illness. During an interview on 8/14/24 at 1:32 p.m., RN-B indicated there were no audible alarms in the isolation rooms and if negative pressured had been disrupted staff would not know without looking at the panel. RN-B further indicate no routine checks were completed by nursing staff on the floor. During an interview on 8/14/24 at 2:15 p.m., RN-C indicated there were no alarms for the negative pressure rooms. RN-C further indicated the panel would change to red, but nursing staff would have to constantly check the color on the panels to make sure they were working properly. Per manufacture policy titled SRCM Room Condition Monitor dated 9/22/14, Whether a room is to be maintained at a negative pressure to prevent contaminants from escaping into adjacent areas or positive pressure to protect patients with compromised immune systems, the proper pressurization of the room is essential. To assure proper pressurization is maintained in these critical environments, a room pressure monitor is employed to measure and alert staff and personnel of any change in pressure-no matter how small. Alarm capabilities. -Local audible and visual alarming -Remote annunciator alarming capability -Alarm delay feature-prevent nuisance alarms Facility policy titled Transmission Based Precautions by Pathogen Index 2007; Airborne precautions require negative flow rooms. Facility policy Standard and Isolation Precautions no date, Precautions are used to reduce the risk of transmission of microorganisms from recognized and unrecognized sources of infection. In addition to standard precautions there are three types of transmission-based precautions - Contact, Droplet, and Airborne. Some diseases use a combination of each of these precautions. Patients requiring Isolation Precautions will be placed in a private room. Patients can cohort if they have the same infection.”

“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: 40948 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 tag: K0521 for additional information.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 40948 Based on observation, interview and document review, the facility failed to ensure outdated medications were not available for patent use. Findings included: During observation on 8/14/24 at 10:15 a.m., a medication list was on a malignant hyperthermia (a disease that causes a fast rise in body temperature and severe muscle contractions when someone receives general anesthesia) cart. The list identified six boxes of dantrolene (a medication uses to reverse severe muscle contractions) which had an expiration date of 2/2024. During an interview on 8/14/24 at 10:20 a.m., the certified registered nurse anesthetist (CRNA) stated the list on the malignant hyperthermia cart (the cart) identified the expiration dates of the medications inside. Stated when the cart was last checked by surgery staff on 1/30/24, and the medications were not expired at that time. It is pharmacy’s responsibility to check the medications on the cart. During an interview on 8/14/24 at 2 p.m., the pharmacy manager stated it was the pharmacy’s responsibility to check the expiration dates in the emergency cart and the malignant hyperthermia cart and replace them when expired. The pharmacy used TraySafe system and identified expiration dates of medications in the carts around the hospital. When the TraySafe system was implemented the cart in the surgery department was missed and the medication was expired. During an interview on 8/14/24 at 2:15 p.m. the director of nursing (DON) stated she would have expected the medications in the cart would have expiration dates monitored. If staff identified expired medications, they would be expected to inform pharmacy to have the medications changed out. The facility’s undated Medication Security, Storage and Handling policy identified all drug storage areas will be inspected monthly for missing or outdated medications.”

“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: 48583 Based on interview and medical record review, the critical access hospital (CAH) failed to ensure patients received consents for treatment for 9 of 16 (P7, P35, P36, P38, P42, P45, P37, P39 and P6.) and the Important Message from Medicare (IMM) for 11 of 16 (P7, P34, P35, P36, P38, P37, P39, P1, P4, P5 and P6) patients who were admitted to inpatient status or swing bed status. Findings include: A review of medical records and interview was completed on 8/14/24 at 3:38 p.m., with assistant director of nursing (ADON) The review revealed the following: P34 was admitted on 2/14/24, as an inpatient for a traumatic subdural hematoma (bleeding in the brain). A review of the medical record with ADON revealed the IMM was verbally signed and not dated. P35 was admitted on 2/20/24, as an inpatient for a prostate neoplasm (prostate cancer). A review of the medical record with ADON revealed the consent to treat was not signed or dated. Additionally, the IMM was not found in P35’s medical record. P36 was admitted on 3/11/24, as an inpatient for cellulitis (bacterial infection of the skin bacterial infection of the skin) of the right lower extremity. A review of the medical record with ADON revealed the consent to treat was signed and dated two days after admission. Additionally, the IMM was not found in P36’s medical record. P37 was admitted on 3/25/24, as an inpatient for dehydration. A review of the medical record with ADON revealed the consent to treat was not signed or dated. Additionally, the IMM was not found in P37’s medical record. P38 was admitted on 4/16/24, as an inpatient for an intestinal obstruction. A review of the medical record with ADON revealed the consent to treat was not signed or dated. Additionally, the IMM was not found in P38’s medical record. P39 was admitted on 4/25/24, as an inpatient for cognitive impairment. A review of the medical record with ADON revealed the consent to treat was not signed or dated. Additionally, the IMM was not found in P39’s medical record. P38 was admitted on 6/13/24, as an inpatient for pneumonia and failure to thrive. A review of the medical record with ADON revealed the consent to treat was not signed or dated. Additionally, the IMM was not found in P38’s medical record. P42 was admitted on 6/25/24, as an inpatient for sepsis (an infection of the blood stream). A review of the medical record with ADON revealed the consent to treat was signed verbal and not dated. P7 was admitted on 7/30/24, as a swing-bed inpatient for a left femur fracture. A review of the medical record with ADON revealed the consent to treat was not signed or dated. Additionally, the IMM was not found in P7’s medical record. P5 was admitted on 8/6/24, as a swing-bed inpatient for COVID, dehydration and diabetes. A review of the medical record with ADON revealed the IMM was not found in P5’s medical record. P6 was admitted on 8/6/24, as an inpatient for low back pain. A review of the medical record with ADON revealed the consent to treat was signed and dated two days after admission. Additionally, the IMM was not found in P6’s medical record. P4 was admitted on 8/9/24, as a swing-bed inpatient for a left humerus fracture. A review of the medical record with ADON revealed the consent to treat was not signed or dated. Additionally, the IMM was not found in P4’s medical record. P45 was admitted on 8/9/24, as an inpatient for hypomagnesium (elevated magnesium levels). A review of the medical record with ADON revealed the consent to treat was not signed or dated. Additionally, the IMM was not found in P45’s medical record. P1 was admitted on 8/10/24, as an inpatient for bilateral (both) lower extremity infection. A review of the medical record with ADON revealed the consent to treat was not signed or dated. Additionally, the IMM was not found in P1’s medical record. During an interview on 8/14/24 at 5:47 p.m., director of nursing (DON) and infection preventionist (IP) confirmed consent forms and IMM’s are signed during admissions to the hospital. DON and IP indicated the forms are hand signed and scanned into the resident’s medical chart. In an email dated 8/15/24 at 1:41 p.m., and 8/15/24 at 3:47 p.m., DON confirmed the facility was only able to find a few consents and IMM’s. According to the Centers for Medicare and Medicaid, “Hospitals are required to deliver the Important Message from Medicare (IMM), formerly CMS-R-193 and now CMS-10065, to all Medicare beneficiaries (Original Medicare beneficiaries and Medicare Advantage plan enrollees) who are hospital inpatients. The IM informs hospitalized inpatient beneficiaries of their hospital discharge appeal rights.””

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 47263 Based on observation, interview and record review, the facility failed to implement infection prevention measures to ensure all medical equipment and supplies intended for patient care were stored in a manner that prevented patient exposure to cross contaminated equipment and supplies stored in the dirty utility room. This deficient practice had the potential to impact all patients in the emergency department who required the use of a commode or specimen collection cup. Findings include: On 8/14/24 at 4:32 p.m., registered nurse (RN)-C confirmed the following items were being stored in the emergency department (ED) dirty utility room: a bin of sterile specimen collection cups, boxes of commode bucket liners, and two commodes (a portable bedside toilet). RN-C confirmed the specimen cups were taken out of the dirty utility room and used to collect patient urine samples. RN-C stated nursing and environmental services were responsible for the sanitization of commodes. RN-C stated staff knew commodes in the dirty utility room were sanitized and ready to use because staff only put sanitized commodes in the dirty utility room. RN-C indicated the dirty utility room was not optimal for commode and specimen cup storage due to the risk of cross contamination between dirty and clean items. During an interview on 8/14/24 at 2:57 p.m., the director of nursing (DON) stated the dirty utility room was not an appropriate place to store medical equipment or supplies due to the risk of cross contamination. The DON further indicated they expected commodes to be stored in clean areas, and indicated commodes removed from the dirty utility room should be considered dirty until sanitized. During an interview on 8/14/2024 at 4:42 p.m., the infection preventionist (IP) stated the dirty utility room was a room that was designated for the management of dirty items only and indicated that medical supplies and equipment should not be stored in the dirty utility room due to the risk of patient exposure to cross- contaminants. The IP stated medical equipment temporarily stored in the dirty utility room should be considered dirty, and indicated once removed, it was expected that equipment would be properly sanitized prior to use or placement in clean storage. The Decontamination of Reusable Medical Equipment dated 09/18/2023, identified all staff as responsible for the sanitization of commodes between patients and directed staff on proper steps for cleaning and sanitizing commodes. The policy did not define or direct staff on proper storage of sanitized reusable medical equipment. The facility Infection Prevention Plan dated 09/19/2023, Section A. Work Practice and Engineering Controls, item eight subtitled: Equipment and Supplies referred staff to the Decontamination of Reusable Medical Equipment policy and indicated all staff were responsible for equipment decontamination immediately after use/or contamination. The plan did not address the proper storage of medical supplies or include infection prevention measures for clean and dirty storage areas.”

“FREEDOM FROM ABUSE, NEGLECT & EXPLOITATION CFR(s): Freedom from abuse, neglect and exploitation (§483.12(a)(1), (a)(2), (a)(3)(i), (a)(3)(ii), (a)(4), (b)(1), (b)(2), (c)(1), (c)(2), (c)(3), and (c)(4) of this chapter). “ §483.12(a)(1) Freedom from abuse, neglect, and exploitation. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms.(a) The facility must-(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; “ §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. “ §483.12(a)(3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. “ §483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. “ §483.12(b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, “ §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This Standard is not met as evidenced by: 47263 Based on interview and record review the facility failed to obtain provider orders for the application of physical restraints for 2 of 2 patients (P29, P46) who were reviewed for restraint use in the emergency department (ED) for management of behaviors that posed an imminent danger to the safety and wellbeing of self and others. Findings include: P29 arrived at the ED via ambulance on 12/23/23 at 1:50 a.m., with the chief complaint of suicidal ideation and alcohol use. On 12/24/23 at 7:12 a.m., P29 required the use of physical restraints to manage threating and destructive behavior. The provider wrote an order for 1:1 observation but did not write an order for restraint application or discontinuation. P46 arrived at the ED via ambulance in restraints on 3/24/24 at 4:49 p.m., with the chief complaint of alcohol use and psychiatric problems. P46 had received ketamine, was placed in restraints in the ambulance prior to arrival at the ED. Restraints were removed upon arrival to the ED. At 6:30 p.m., P46 required the use of physical restraints due to behaviors that were a safety threat to self and others. The provider placed orders for 1:1 observation however did not enter orders for the application or discontinuation or restraints. During record review on 8/14/24 at 11:30 a.m., registered nurse (RN)-C verified P29 and P24’s medical records lacked provider orders for the application and discontinuation of restraints. During an interview on 8/14/24 at 2:48 p.m., the director of nursing (DON) stated it is a requirement to have a provider enter orders for restraint use. The expectation is that the provider would put in an order for restraint application, and ongoing use. It is the nurse’s responsibility to make sure the medical record has provider orders to cover the care they have provided to the patient. Restraint training gets done when hired and then annually. We just completed hands on restraint education and competency in May of this year [2024], and restraint orders were included in the training. The facility policy Psychiatric Emergencies dated 6/26/24, indicated patients with suicidal, homicidal, and or high potential for violence or elopement required placement on continuous 1:1 visual observation and outlined safety and care measurements to be followed. The facility policy Restraints Seclusion dated 3/29/24, was requested, but not received. The facility undated employee restraint application competency Twice-As-Tough Cuffs included line item 15. which instructed staff to ensure an order was placed by the provider for restraint use.”

“DENTAL SERVICES CFR(s): Dental Services (§483.55(a)(2), (3), (4), and (5) and (b) of this chapter). “ §483.55 Dental services. The facility must assist residents in obtaining routine and 24-hour emergency dental care. (a) Skilled nursing facilities. A facility- (2) May charge a Medicare resident an additional amount for routine and emergency dental services; (3) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility’s responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility’s responsibility; (4) Must if necessary or if requested, assist the resident- (i) In making appointments; and (ii) By arranging for transportation to and from the dental services location; and (5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay. (b) Nursing facilities. The facility- (1) Must provide or obtain from an outside resource, in accordance with §483.70(g), the following dental services to meet the needs of each resident: (i) Routine dental services (to the extent covered under the State plan); and (ii) Emergency dental services; (2) Must, if necessary or if requested, assist the resident- (i) In making appointments; and (ii) By arranging for transportation to and from the dental services locations; (3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay; (4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility’s responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility’s responsibility; and (5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan. This Standard is not met as evidenced by: 48583 Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure the dental services agreement was current and signed by the dental provider for swing bed patients to have available to them. This had the potential to affect all swing bed patients that were admitted to the hospital. Findings include: During an interview on 8/14/24 at 1:05 p.m., director of nursing (DON) confirmed the CAH does not have a dental agreement with a provider for dental services for swing bed patients. DON indicated they have tried to get one in the past but have been unsuccessful. DON further indicated if a patient needed dental services the CAH would try to get them into their personal dentist or try to find a dentist to assist. A dental agreement was requested however, one was not provided. A dental policy was requested however, one was not provided.”

“NUTRITION CFR(s): Nutrition (§483.25(g)(1) and (g)(2) of this chapter). “ §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident’s comprehensive assessment, the facility must ensure that a resident- (1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident’s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; (2) Is offered sufficient fluid intake to maintain proper hydration and health. This Standard is not met as evidenced by: 48583 Based on record review and interview, the Critical Access Hospital (CAH) failed to assure nutritional needs of inpatients and swing bed patients were met in accordance with recognized dietary practices and the orders of the practitioner responsible for the care of the patients. During an interview on interview on 8/14/24 at 11:42 a.m., certified dietary manager (CDM) indicated if a resident needed a special diet or was at risk for malnutrition the nursing staff would have been responsible to work with the provider on the diet. During an interview on 8/14/24 at 1:27 p.m., registered nurse (RN)-B indicated the providers had put the diet orders in when a patient is admitted. RN-B further indicated nursing completes a nutritional assessment on each newly admitted patient. RN-B stated they would be responsible to monitor a patients nutritional needs and report changes to the provider. RN-B further stated they do not have additional nutritional support from a registered dietician. During an interview on 8/14/24 at 2:05 p.m., director of nursing (DON) confirmed the CAH does not have a registered dietician available for inpatients. DON indicated the providers place diet orders and nursing staff monitor the orders. Facility policy titled Nutrition Risk, Screen, and Assessment: Acute Care, not dated, the registered dietician nutritionist (RDN) will perform a comprehensive nutrition assessment on any patient who is screened at risk for malnutrition. The RDN will perform a comprehensive nutrition assessment on patients admitted to swing bed.”

“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: 47263 Based on interview and document review the facility failed to develop a comprehensive Emergency Preparedness Plan (EPP) to include the provision of food. This has the potential to affect all patients and staff. Findings include: The facility Emergency Preparedness plan dated 9/13/23, lacked evidence of a plan to have food provisions on hand to support the nutritional needs of patients and staff in the event of an emergency that required an evacuation or sheltering in place. During an interview on 8/14/24 at 5:12 p.m., the emergency preparedness coordinator confirmed a policy and procedure for the subsistence needs of food was not included in the EPP.”

“FIRE SAFETY A Recertification Life Safety Code survey was conducted by the Minnesota Department of Public Safety, State Fire Marshal Division on August 13, 2024. At the time of this survey, Mille Lacs Health Systems CAH was found not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR, Subpart 485.623(d), Life Safety from Fire, and the 2012 edition of National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 18 New Health Care 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. Mille Lacs Health System CAH Building 03 is licensed as a Critical Access Hospital and is a two-story building with no basement. The building was constructed in 2021 and was 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 licensed capacity of 25 beds and had a census of 6 at the time of the survey. The requirement at 42 CFR, Subpart 485.623(d) is NOT MET as evidenced by:”

“FIRE SAFETY A Recertification Life Safety Code survey was conducted by the Minnesota Department of Public Safety, State Fire Marshal Division on August 13, 2024. At the time of this survey, Mille Lacs Health Systems CAH was found not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR, Subpart 485.623(d), Life Safety from Fire, and the 2012 edition of National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care 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. Mille Lacs Health System CAH is a 1-story building with no basement. The original building was constructed in 1955 with additions in 1981 and 1999. The original building and additions are all Type II(111) construction. The hospital is connected to the nursing home, clinic, and assisted living facility. They are all properly two hour fire separated. The building is fully fire sprinkler protected. The facility has a complete fire alarm system with smoke detection in the corridors and spaces open to the corridors, that are monitored for automatic fire department notification. The facility has a licensed capacity of 25 beds and had a census of 6 at the time of the survey. The requirement at 42 CFR, Subpart 485.623(d) is NOT MET as evidenced by:”

“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: 34764 Based on a review of available documentation and staff interview, the facility failed to inspect fire dampers per NFPA 101 (2012 edition), Life Safety Code, section 8.5.5.4.2, and NFPA 105 (2010 edition), Standard for Smoke Door Assemblies and Other Opening Protectives, section 6.5.2. This deficient finding could have a widespread impact on the residents within the facility. Findings include: On 08/13/2024 between 09:30 AM and 12:30 PM, it was revealed by a review of available documentation that the facility could not provide documentation that the completed inspections were performed on the fire dampers at the time of the survey. An interview with the Faciliities Manager verified this deficient finding at the time of discovery.”

“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: 34764 Based on a review of available documentation and staff interview, the facility failed to inspect fire dampers per NFPA 101 (2012 edition), Life Safety Code, section 8.5.5.4.2, and NFPA 105 (2010 edition), Standard for Smoke Door Assemblies and Other Opening Protectives, section 6.5.2. This deficient finding could have a widespread impact on the residents within the facility. Findings include: On 08/13/2024 between 09:30 AM and 12:30 PM, it was revealed by a review of available documentation that the facility could not provide documentation that the completed inspections were performed on the fire dampers at the time of the survey. An interview with the Faciliities Manager verified this deficient finding at the time of discovery.”