Essentia Health Deer River

“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: 27955 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: F321, F324, F353, F702, and F920 for additional information.”

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 27955 Based on interview and document review, the critical access hospital (CAH) failed to ensure policies and procedures in the nursing department were reviewed every two years. In addition, the facility failed to ensure policies were reviewed for clinical records and radiology biannually. Findings include: Review of clinical record policies and radiology policies revealed the following were not reviewed biannually: Clinical Records Policies -Access, Use, and Disclosure of Protected Health Information last review date 6/14/2022. -Electronic Signatures last review date 2/14/2022. -Retention of Non-Electronic Medical Records last review date 9/10/2019. -Physician Orders-Telephone, Verbal Order last review date 11/17/2021. Radiology Policy -Radiation Safety (ALARA) last review dated 2/9/2021. 42587 Review of nursing policies and procedures revealed the following: NURSING -Reportable Events-Adverse Health Events and TJC Sentinel Events last review date 5/22/22. -Employee Orientation last review date 2/27/22. -Staff Competence last review date 10/23/20 During an interview on 6/25/24 at 10:05 a.m., the director of nursing (DON) stated clinical policies were reviewed internally every two years however any policies which were administrative were not part of this review process. The DON verified the above policies had not been reviewed in the two year time frame. During an interview on 6/27/24 at 8:25 a.m., the administrator verified the above policies were not part of the every two year review process.”

“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: 42587 Based on interview and medical record review, the hospital failed to ensure patients received the Important Message from Medicare (IMM) for 4 of 6 (P1, P6, P9, P13) patients who were admitted to inpatient status or swing bed status. Findings include: A review of medical records and interview was completed on 6/27/24 at 12:00 p.m. with registered nurse (RN)-A and administrator present. The review revealed the following: P1 was admitted on 6/23/24, as an inpatient with weakness and fever. A review of the medical record with RN-A and with the administrator revealed the IMM was not found in P1’s medical record. Administrator verified the record lacked an IMM. P6 was admitted on 4/12/24, in a swing bed status for wound care. A review of the medical record with RN-A and with the administrator revealed the IMM was not found in P6’s medical record. Administrator verified the record lacked an IMM. P9 was admitted on 5/8/24, as an inpatient for urinary tract infection with an indwelling urinary catheter. A review of the medical record with RN-A and with the administrator revealed the IMM was not found in P9’s medical record. Administrator verified the record lacked an IMM. P13 was admitted on 6/26/24, as an inpatient for upper gastrointestinal bleed. A review of the medical record with RN-A and with the administrator revealed the IMM was not found in P13’s medical record. Administrator verified the record lacked an IMM. According to the Centers for Medicare and Medicaid, “Hospitals are required to deliver the Important Message from Medicare (IM), 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.””

“FIRE SAFETY An annual Life Safety recertification survey was conducted by the Minnesota Department of Public Safety, State Fire Marshal Division on 06/25/2024. At the time of this survey, Deer River Healthcare Center - 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 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. Deer River Healthcare (Hospital) was built at various times. The Main building consists of the original construction was in 1960 which is 1-story, no basement and determined to be Type II (111) construction. In 1973 additions to that building were constructed, are 1-story, no basement and Type II (000) construction with a partial fire sprinkler system. In 1984 an addition that is 1-story has a partial basement, was determined to be Type II (222) and fully sprinkler protected was constructed. The 1994 ambulance garage/ clinic additions were added, are 1-story, with a basement and Type II (111) with a full fire sprinkler system. In 2000 a corridor addition connecting the clinic and the hospital was built, it is 1-story, no basement and Type II (111) construction with a full fire sprinkler system. The 2008 building is 1-story, has a partial basement and Type II (000) construction with a complete fire sprinkler system and is separated with 2-hour fire barriers from the existing hospital and clinic. The hospital is separated from the Homestead Nursing Home to the north with 2- hour fire rated construction. Essentia Health Grand Rapids Clinic is a suite of rooms on the main level in the southeast corner of this professional office building was constructed in 2000 is 1-story building with a partial basement and was determined to be Type II (000) constructed. The facility has a capacity of 16 beds and had a census of 0 at the time of the survey. The requirements at 42 CFR, Subpart 483.70(a), are 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: 45748 Based on observation and staff interview, the facility failed to maintain hazardous storage rooms per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.1.3 and 7.2.1.8.1. These deficient finding could have a patterned impact on the residents within the facility. Findings include: On 06/25/2024 between 10:00am and 2:00pm, it was revealed by observation that storage room / office areas that require self closers did not have a self-closing device in the following areas: 1) ER142 Room 2) ER144 Room 3) W118 Room 4) Decontamination storage room 5) CL141B Lab Door An interview with the Director of Maintenance verified these deficient findings at the time of discovery.”

“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: 45748 Based on observation, a review of available documentation, and staff interview, the facility failed to install the required safety features for cooking equipment per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.5.3 (9) and 19.3.2.5.4. This deficient finding could have an isolated impact on the residents within the facility. Findings include: On 06/25/2024 between 10:00am and 2:00pm, it was revealed by observation that the residential stove located in physical therapy was not equipped with a lock-out switch and was not on a timer, not exceeding a 120-minute capacity, that automatically deactivates the cook-top or range, independent of staff action. An interview with the Director of Maintenance 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: 45748 Based on observation and staff interview, the facility failed to maintain spacing between storage and the sprinkler system per NFPA 101 (2012 edition), Life Safety Code, Section 9.7.5, NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Section 5.2.1.2, and NFPA 13 (2010 edition), Standard for the Installation of Sprinkler Systems, Sections 8.6.5.3.2 and 8.15.9. These deficient findings could a patterned impact on the residents within the facility. Findings include: On 06/25/2024 between 10:00am and 2:00pm, it was revealed by observation that storage materials had been placed on a storage rack, bringing the storage materials within the required 18 inch clearance area under the sprinkler heads. These obstructions were found in: An interview with the Director of Maintenance verified these deficient findings 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: 45748 Based on observation and staff interview, the facility failed to maintain their smoke barrier per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.7.1, 19.3.7.3, 8.5.2.2, and 8.5.6.5. These deficient findings could have a widespread impact on the residents within the facility. Findings include: On 06/25/2024 between 10:00am and 2:00pm, it was revealed by observation that there was a penetration running from one smoke compartment to another on the Lower Level mechanical room. An interview with the Director of Maintenance verified these deficient findings at the time of discovery.”

“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: 45748 Based on observation and staff interview, the facility failed to maintain the usage of electrical adaptive devices per NFPA 99 (2012 edition), Health Care Facilities Code, sections 10.5.2.3.1 and 10.2.4.2.1, NFPA 70, (2011 edition), National Electrical Code, sections 400-8, and UL 1363. This deficient finding could have an isolated impact on the residents within the facility. Findings include: On 06/25/2024 between 10:00am and 2:00pm, it was revealed by observation that there were several electrical appliances plugged into a power strip in the following areas: 1) Maintenance room L011 2) Scheduling Office in surgery area An interview with the Director of Maintenance verified these deficient findings at the time of discovery.”