Panola Medical Center

“EMERGENCY ROOM LOG CFR(s): [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 42975 Based on staff interview and facility policy review, Hospital #1 failed to maintain a central log of all individuals who come to the Emergency Department (ED) seeking medical treatment to ensure the required information (refused treatment, was refused treatment, transferred, admitted and treated, stabilized and transferred, or discharged) was documented. This deficient practice affected one (1) out of 11 sampled patients, Patient #11. Findings Include: An interview on 05/21/2025 at 4:22 p.m. with the Registration Clerk confirmed a family member’s sister presented to the clerk’s desk stating her sister, Patient #11, was in labor and having contractions in the car. The Registration Clerk alerted the nurses that a pregnant lady in active labor was outside. The Registration Clerk also confirmed that the patient was not added to the ED Central Log because the sister did not provide a name. In an interview on 05/22/2025 at 12:05 p.m. with Registered Nurse (RN) #1 it was confirmed that Patient #11 was not added to the ED log, a medical screening exam (MSE) was not provided, and a transfer was not offered. Review of the facility’s “EMTALA [Emergency Medical Treatment and Labor Act]” policy dated 09/13/2023 revealed “ ...C. Central Log 1. The Hospital must maintain a central log of individuals who come to the emergency department and include in such log whether such individuals refused treatment, were refused treatment, or whether such individuals were treated, stabilized, and/or transferred or were discharged. The log must register all patients who are present for examination or treatment even if they leave prior to triage or MSE [Medical Screening Exam] ...2. The hospital had the discretion to maintain the central log in a form that best meets the needs of the hospital...” During the exit conference on 05/22/2025 with the Chef Executive Officer, Director of Admissions/Safety Officer, and the Director of Nursing findings were discussed, and no further documentation was submitted for review. Cross Refer to O2406 and O2409.”

“MEDICAL SCREENING EXAM CFR(s): (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 42975 Based on staff interviews, medical record review, and facility policy review, Hospital #1 failed to complete a Medical Screening Exam (MSE) within the capability of the hospital’s Emergency Department (ED) for an individual who was pregnant and having contractions on arrival to the ED for one (1) out of 11 sampled patients, Patient #11. Findings Include: In an interview on 05/22/2025 at 12:05 p.m. with Registered Nurse (RN) #1 it was confirmed that a medical screening exam (MSE) was not provided for Patient #11 on arrival to the ED on 05/13/2025. Patient #11 presented after midnight with complaint of contractions every three (3) minutes with no report of ruptured membranes. Patient #11 reported her Obstetrician was located at Hospital #2, but they (Patient #11 and her sister) stopped at Hospital #1 due to the frequency of her contractions. RN #1 explained the facility had an ED but did not have an Obstetric or Labor and Delivery Unit, but she could see a Provider at Hospital #1. Patient #11 asked if she should stay at Hospital #1 or travel to Hospital #2, which was 24 miles away. RN #1 said she would ask the facility ED Provider. RN #1 reported the ED Provider #1 advised Patient #11 to go to Hospital #2 now. No Medical Screening Exam (MSE) was provided before Provider #1’s recommendation for Patient #11 to proceed to Hospital #2. RN #1 informed Patient #11 and her caregiver of the recommendation and the Patient left Hospital #1. There was no medical record generated for Patient #11 at Hospital #1 for surveyor review. Review of medical record for Patient #11 from Hospital #2 revealed she presented to the ED ambulance bay in a private vehicle with family member on 05/13/2025. Hospital #2’s ED nurse called their Obstetric ED at 6:58 a.m. to report a patient presenting with a delivered baby in a car. Patient #11 reported she delivered about two (2) minutes prior to arrival and reported her water ruptured approximately one (1) minute prior to delivery. Medical record revealed the baby was not in distress, was crying with good tone and pink in color and umbilical cord intact. ED nurse clamped and cut the cord using a sterile technique and Patient #11 was taken to the Labor and Delivery Unit for placenta delivery and the baby was taken to the Newborn Nursery unit. Hospital #2’s medical record also revealed the delivery was a non-sterile, non-controlled, spontaneous vaginal delivery in the patient’s car. The placenta was also spontaneously delivered intact with a three (3) vessel cord, perineum intact, no lacerations. Review of Hospital #1’s policy titled “EMTALA [Emergency Medical Treatment and Labor Act],” dated 9/13/23 revealed “...POLICY: if an individual comes to the ED: A. The hospital will provide an appropriate MSE within the capability of the hospitals dedicated ED, including ancillary services routinely available, to determine whether an emergency medical condition exists. B. The hospital will: (a) provide an individual who is determined to have an emergency medical condition such further medical examination and treatment is required to stabilize the emergency condition, or (b) arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below ...” During the exit conference on 05/22/2025 with the Chef Executive Officer, Director of Admissions/Safety Officer, and the Director of Nursing findings were discussed, and no further documentation was submitted for review. Cross Refer to O2409.”

“Compliance with Federal, state, and local law CFR(s): (a)The REH must be in compliance with applicable Federal laws related to the health and safety of patients. (b) The REH must be located in a state that provides for the licensing of such hospitals under state or applicable local law; and is (1) Licensed in the state as an REH; or (2) Approved as meeting standards for licensing established by the agency of the state or locality responsible for licensing hospitals. (c) The REH must assure that personnel are licensed or meet other applicable standards that are required by state or local laws to provide services within the applicable scope of practice. This Condition is not met as evidenced by: 47941 Based on facility staff interviews and documentation reviews, the facility failed to ensure compliance with state laws and regulations regarding the availability of required reference Laboratory testing capability essential to the diagnosis and treatment of the patients presenting for emergency services and failed to ensure a current laboratory services contract for four (4) of (4) days of survey. Findings Include: During an Interview on 03/10/2025 at 11:03 a.m., the Laboratory Manager confirmed “ ...we lost our contract with LabCorp on February 10, 2025 ...”. During an interview on 03/11/2025 at 10:22 a.m., the Chief Executive Officer confirmed “ ...no active contract with LabCorp due to nonpayment ...”. During an interview on 03/11/2025 at 12:15 p.m., the Emergency Department Medical Director confirmed we receive emails weekly letting us know ...not available for lab test unable to order. Further confirms we are unable to order urine or blood cultures for our patients. During an interview on 03/12/2025 at 10:49, the Laboratory Manager confirmed “ ...no reference labs are sent out. There is nowhere to send them ... required reference laboratory tests ... include Anticonvulsant and other therapeutic drug level, Cardiac Isoenzymes (including Creatine Kinase-MB), Chloride (Blood and Cerebral Fluid),Methemoglobin, Osmolality, Protein Cerebrospinal Fluid (CSF), CSF and Joint fluid analysis, Sickle Cell prep, Acid Fast Smear/Staining, Chlamydia testing, Counter immune electrophoresis for Bacterial identification, Gram Staining and Culture/Sensitivities, Herpes testing, Streptococcus (Strep) Screening, Viral Culture, Wright Stain, Hepatitis screening, Human Immunodeficiency Virus (HIV) screening, Mononucleosis spot testing.” Review of the facility document titled “Bylaws of the Governing Body” dated November 18, 2018 revealed “Section 2.1 Governing Body ... The Governing Body shall oversee the Hospital’s management, operations and compliance with applicable regulations...Section 2.6 ...The Governing Body must be responsible for services furnished in the Hospital ...Section 2.7 ...the hospital must comply with all applicable state and federal regulations ...”. No evidence of a current, signed, dated laboratory contract was submitted for review. During the exit conference on 03/12/2025 at 10:45 a.m. with the Chief Executive Officer, Director of Nursing, and the Safety Officer survey findings were discussed and no further documentation was provided for review.”

“COMPLIANCE WITH 489.24 CFR(s): [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 42975 Based on review of hospital records, staff interviews and hospital policy and procedure, it was determined that the hospital failed to obtain or attempt to obtain written and informed refusal of an appropriate transfer for one (Patient #1) of 21 medical records reviewed. Patient #1 was driven by her spouse to Hospital #2 and delivered her baby within five (5) minutes of arrival. Hospital #1’s failure to provide an appropriate transfer, or document Patient #1’s refusal of transfer via Emergency Medical Services (EMS), placed the patient and her unborn child at increased risk of illness, organ dysfunction, and/or death. Findings Include: A review of Patient #1’s Emergency Department (ED) medical record titled, “Emergency Room Nursing Note” documented the patient arrived at the ED on 01/13/2025 at 8:38 a.m. in “Mild Distress” with 10 out of 10 abdominal pain described as cramping. The description of the pain was noted as diffuse, moderate in severity, radiating to her back with a duration of 45 minutes. Hospital nursing staff documented Patient #1’s “Labor/Pregnancy Focused Assessment” as sudden onset with normal fetal movement and Fetal Heart Tones at 146 beats per minute. Nursing staff documented Patient #1 was 39 weeks pregnant and having contractions at three (3) minutes apart. A nursing note documented at 8:45 a.m. noted, “MD [Physician #1 last name] went in and assess patient and patient water hadn’t broke and patient and spouse made the choice to leave PMC [Panola Medical Center] ED and head to Baptist Oxford where they offer labor and delivery services.” A nursing note timed at 8:50 a.m. documented “Patient leaves ED by POV [Privately Owned Vehicle] headed to Baptist Oxford.” The hospital nursing note documented Patient #1 was discharged “Home” accompanied by her spouse at 8:55 a.m. The “Transfer” section of the note was marked “N/A [Not Applicable].” Cross Refer to O2409.”

“APPROPRIATE TRANSFER CFR(s): (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 42975 Based on review of hospital records, staff interviews and hospital policy and procedure, it was determined that the hospital failed to obtain or attempt to obtain written and informed refusal of an appropriate transfer for one (Patient #1) of 21 medical records reviewed. Patient #1 was driven by her spouse to Hospital #2 and delivered her baby within five (5) minutes of arrival. Hospital #1’s failure to provide an appropriate transfer, or document Patient #1’s refusal of transfer via Emergency Medical Services (EMS), placed the patient and her unborn child at increased risk of illness, organ dysfunction, and/or death. Findings Include: A review of Patient #1’s hospital medical record, “ER Provider Note” dated 01/13/2025 at 8:56 a.m., documented by Physician #1 revealed “Chief Complaint: 9 month OB contractions, 37 weeks gestation; c/o [complaint of] abdominal pain; possible early labor; contractions every 5 minutes; denied breaking her water; denied any vaginal bleeding; trauma / fall or injury.” The ED Provider Physical Exam documented, “ED course: Patient refused vaginal exam: possible to break water during the exam; husband at bedsite [sic]; decided to go to Baptist [O]xford for further evaluation and treatment. Initial Impression: active labor. Differential Diagnoses: Braxton [H]icks contractions / active labor / false labor.” Interview with Registered Nurse (RN) #1 on 02/11/2025 at 4:30 p.m., conveyed Physician #1 exited Patient #1’s room and stated, “They refused an exam, and they are going to [Hospital #2].” RN #1 said she then assisted the patient into a wheelchair and to their personal vehicle. Further interview with RN #1 revealed they did not offer an AMA (against medical advice) form because Patient #1 was discharged. Interview with Physician #1 on 02/12/2025 at 10:10 a.m. revealed Patient #1 presented with labor pain requesting pain medication. After triage, appropriate staff were called to the Emergency Department (ED) for a live birth and to obtain supplies and equipment to support a live birth. Physician #1 confirmed while trying to complete an assessment to determine the plan of care for delivery or transfer, Patient #1 refused a vaginal examination and just wanted pain medication. Physician #1 said he explained the need for further assessment to make an appropriate plan of care, but the patient and husband refused and said they wanted to go Hospital #2 since this facility [Panola Medical Center] does not provide labor and delivery services. Physician #1 revealed he encouraged the Patient #1 to go by Emergency Medical Transport Services (EMS) and explained the timeline for transport. Physician #1 said the husband chose to go to Hospital #2 by private vehicle. Physician #1 said he instructed the staff nurse to have the patient and husband sign an Against Medical Advice (AMA) form. Review of the hospital’s Emergency Medical Treatment and Labor Act (EMTALA) policy, last review date 09/13/2023, no policy number revealed: “Purpose: The purpose of this policy is to set forth policies and procedures for Panola Medical Center’s use in complying with requirements of the Emergency Medical Treatment and Labor Act (EMTALA).” “Policy: H. Transfer of Unstable Individuals 1. A decision regarding patient transfer may be made by either patient request or physician certification. a. Upon Individual request. An individual may be transferred if the individual or the person acting on the individual’s behalf is fully informed of the risks of the transfer, the alternatives (if any) to the transfer, and of the Hospital’s obligations to provide further examination and treatment sufficient to stabilize the individual’s emergency medical condition, and to provide for an appropriate transfer. The transfer may then occur if the individual or person acting on the individual’s behalf: (i) makes a request for transfer to another medical facility, stating the reasons for the request (document reason for request on the transfer form or in the medical record); and (ii) acknowledges his or her request and understanding of the risks and benefits of the transfer in writing;” “2. When the Hospital transfers an individual with an unstabilized emergency medical condition to another facility, the transfer shall be carried out in accordance with the following procedures. a. The Hospital shall, within its capability, provide medical treatment that minimizes the risks to the individual’s health and, in the case of a woman who is having contractions, the health of the unborn child. b. A representative of the receiving facility must confirm that: (1) The receiving facility has available space and qualified personnel to treat the individual; and (2) The receiving facility agrees to accept transfer of the individual and to provide appropriate medical treatment. c. The hospital must send to the receiving facility copies of all pertinent medical records available at the time of transfer, including: (1) history; (2) records related to the individual’s emergency medical condition; (3) observations of signs and symptoms; (4) preliminary diagnoses; (5) results of diagnostic studies or telephone reports of the studies; (6) treatment provided; (7) results of any tests; (8) the written patient consent or physician certification to transfer; ... d. The transfer must be affected through appropriately trained professionals and transportation equipment, including the use of necessary and medically appropriate life support measures during the transfer. The physician is responsible for determining the appropriate mode of transport, equipment, and transporting professionals to be used for the transfer. J. Enforcement All Hospital staff and Medical Staff whose responsibilities are affected by this policy are expected to be familiar with the basic procedures and responsibilities created by this policy. Failure to comply with this policy will be subject to appropriate performance management pursuant to all applicable policies and procedures, including the Medical Staff Bylaws, Rules, and Regulations.” A review of Patient #1’s medical record from Hospital #2 documented she presented on 01/13/2025 at 9:32 a.m., with a chief complaint of “Laboring” with regular contractions. Patient #1 had a spontaneous vaginal delivery on 01/13/2025 at 9:41 a.m. Hospital #1’s medical record failed to document the reason for Patient #1’s refusal of a transfer, being fully informed of the risks of the transfer, the alternatives (if any) to the transfer, and of the Hospital’s obligations to provide further examination and treatment sufficient to stabilize Patient #1’s emergency medical condition, and to provide for an appropriate transfer. During the exit conference on 02/13/2025 with the Chef Executive Officer, Chief Strategy Officer, Safety Officer, and Emergency Department Registered Nurse findings were discussed and no further documentation was submitted for review.”

“Compliance with Federal, state, and local law CFR(s): (a)The REH must be in compliance with applicable Federal laws related to the health and safety of patients. (b) The REH must be located in a state that provides for the licensing of such hospitals under state or applicable local law; and is (1) Licensed in the state as an REH; or (2) Approved as meeting standards for licensing established by the agency of the state or locality responsible for licensing hospitals. (c) The REH must assure that personnel are licensed or meet other applicable standards that are required by state or local laws to provide services within the applicable scope of practice. This Condition is not met as evidenced by: 45467 Based on staff interviews and review of the facility’s “Attestation of Compliance for Rural Emergency Hospital Enrollment and Conversion,” the facility failed to ensure they were in compliance with Federal, state, and local laws and regulations requiring policy and procedures for Administration, Staffing, and Ancillary Services for four (4) of four (4) days of survey. Findings Include: During the Entrance Conference, on 08/19/2024 beginning at 1:23 p.m. with the Interim Chief Executive Officer (ICEO), Chief Human Resource Officer (CHR) Emergency Department Director of Nursing (ED DON), Emergency Department Technicians Supervisor, and Certified Registered Nurse Anesthetist (CRNA), the surveyor requested the facility’s policy and procedures for Ancillary Services, Administration, and staffing. An interview with the Interim Chief Executive Officer on 08/21/2023 at 2:46 p.m. confirmed the facility did not have Ancillary Services, Administration, and Staffing policies and procedures for review. Review of the facility’s “Attestation of Compliance for Rural Emergency Hospital Enrollment and Conversion,” dated and signed by the CEO on 09/15/2023, reveals the facility attest to “ ...currently meets and will continue to meet all of the requirements for Rural Emergency Hospitals set forth in the statute and implementing regulations in Subpart E of 42 code of Federal Regulations (CFR) part 485. During exit conference on 08/22/2024 at 12:00 p.m. with an Administration Clerk, Emergency Department Director (EDD), Chief Human Resource Officer (CHRO), Emergency Department Technicians Supervisor, and the Interim Chief Executive Officer (ICEO), survey findings were discussed, and no further documentation was submitted for review.”

“Governing body and organizational structure o CFR(s): There must be an effective governing body, or responsible individual or individuals, that is legally responsible for the conduct of the REH. If an REH does not have an organized governing body, the person or persons legally responsible for the conduct of the REH must carry out the functions specified in this subpart that pertain to the governing body. This Condition is not met as evidenced by: 45467 Based on staff interviews and document review of the facility’s Organizational Chart and the facility’s “Attestation of Compliance for Rural Emergency Hospital Enrollment and Conversion,” the facility failed to have an effective organized governing body or have an identified responsible individual who is legally responsible for the conduct of the Rural Emergency Hospital (REH) and failed to carry out specified functions required by the Governing Body or a responsible individual. This has the potential to affect the safety and quality of care for all patients who present to the facility for services since the enrollment and attestation that the facility meets the requirements for a REH on 09/15/2023 for four (4) or Four (4) days of survey. Findings include: During an Entrance Conference, on 08/19/2024 beginning at 1:23 p.m. with the Interim Chief Executive Officer (ICEO), Chief Human Resource Officer (CHR) Emergency Department Director of Nursing (ED DON), Emergency Department Technicians Supervisor, and Certified Registered Nurse Anesthetist (CRNA), the current Governing Body Bylaws, Medical Staff Rules and Regulations and Governing Body meeting minutes were requested for review. The facility failed to present documented evidence of the “Governing Body Bylaws” and “Governing Body Meeting Minutes”. An interview on 08/22/2024 at 11:48 a.m. with the Emergency Technician Supervisor (ER Tech Supervisor), confirmed the facility has no documented evidence of Governing Body “Meeting Minutes” for review because the facility has not had a Governing Board meeting since the facility’s enrollment and conversion to a Rural Emergency Hospital (REH). An interview on 08/22/2024 at 12:02 p.m. with the Interim Chief Executive Officer (ICEO) confirmed the facility has not had a governing body meeting since the facility enrolled and converted to a REH and the ICEO further confirmed there is no documented evidence a Governing Body or a responsible individual legally responsible for the conduct of the REH has been appointed since the enrollment and conversion of the facility. The ICEO confirmed the facility’s “Medical Staff Rules and Regulations,” with an original date of July 2019 have not been revised/adopted since the conversion to the REH. Review of the facility’s “Attestation of Compliance for Rural Emergency Hospital Enrollment and Conversion,” dated and signed by the CEO at the time of conversion on 09/15/2023, attest to the understanding the facility “ ...must meet all the Conditions of Participation (CoPs) in 42 Code of Federal Regulations (CFR) part 485, subpart E...”. Review of the facility’s “Organizational Chart,” dated 08/01/2024 reveals the Interim Chief Executive Officer (ICEO) is the individual designated who oversees the operation of the facility. The “Organizational Chart” shows no documentation of a Governing Body over the Interim CEO. During exit conference on 08/22/2024 at 12:00 p.m. with an Administration Clerk, Emergency Department Director (EDD), Chief Human Resource Officer (CHRO), Emergency Department Technicians Supervisor, and the Interim Chief Executive Officer (ICEO), survey findings were discussed, and no further documentation was submitted for review. Cross reference O-146/485.510(a) and O-150/485.510(a)(5) for additional information.”

“Medical staff. CFR(s): The REH must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the REH. This Condition is not met as evidenced by: 46164 Based on Staff interview, document review of the facility’s “Organization Chart,” dated 08/01/2024, “Medical Staff Rules and Regulations,” dated July of 2019, and review of the facility’s “Attestation of Compliance for Rural Emergency Hospital Enrollment and Conversion,” dated 09/15/2023, the facility failed to have medical staff operating under current facility Bylaws approved by a designated Governing Body or appointed individual legally responsible for the conduct of the Rural Emergency Hospital (REH) to ensure the quality of medical care provided to its patients. This has the potential to affect all patient’s safety and quality of care since the facility enrolled and attested that the facility meets the requirements for a REH on 09/15/2023 for four (4) of four (4) days of survey. Findings include: During an Entrance Conference, on 08/19/2024 beginning at 1:23 p.m. with the Interim Chief Executive Officer (ICEO), Chief Human Resource Officer (CHR) Emergency Department Director of Nursing (ED DON), Emergency Department Technician Supervisor, and Certified Registered Nurse Anesthetist (CRNA), the surveyor requested the current “Governing Body Bylaws” and “Governing Body Meeting Minutes” for the past twelve (12) months or since the facility enrolled and converted to a REH. An interview on 08/22/2024 with the Emergency Technician Supervisor (ER Tech Supervisor) at 11:48 a.m., confirmed the facility’s “Medical Staff Bylaws” have not been updated since 2019 and the facility has not had a Governing Body meeting for the past twelve (12) months since the facility began service as a Rural Emergency Hospital on November 1, 2023. An interview on 08/22/2024 at 12:02 p.m. with the Interim Chief Executive Officer (ICEO) confirmed the facility has not had a governing body meeting since the facility enrolled and attested that the facility meets the requirements for a REH on 09/15/2023 and the facility’s “Medical Staff Bylaws,” have not been developed/adopted since the conversion to the REH. The interim CEO also confirmed the “Medical Staff Rules and Regulations” have not been updated since 2019 and the facility does not have any “Governing Body Meeting Minutes” for review since the facility enrolled and converted to a REH. The facility failed to present documentation of the “Governing Body Bylaws” and “Governing Body Meeting Minutes”. The facility presented its “Medical Staff Rules and Regulations” which were approved and adopted on 07/12/2019 with no revisions/updates or adoptions since the facility enrolled and attested to the facility’s compliance with the requirements for a REH on 09/15/2023. Review of the facility’s “Organizational Chart,” dated 08/01/2024 reveals the Interim Chief Executive Officer (ICEO) is the individual designated who oversees the operation of the facility. The “Organizational Chart” shows no documentation of a Governing Body over the Interim CEO. Cross Reference to O-140/485.510 for additional information During exit conference on 08/22/2024 at 12:00 p.m. with an Administration Clerk, Emergency Department Director (EDD), Chief Human Resource Officer (CHRO), Emergency Department Technician Supervisor, and the Interim Chief Executive Officer (ICEO), survey findings were discussed, and no further documentation was submitted for review.”

“Provision of services. CFR(s): (c) The policies must include the following: (1) A description of the services the REH furnishes, including those furnished through agreement or arrangement. (2) Policies and procedures for emergency medical services. (3) Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the REH. (4) Policies and procedures that address the post-acute care needs of patients receiving services in the REH. This Condition is not met as evidenced by: 46164 Based on staff interviews and review of the facility’s “Attestation of Compliance for Rural Emergency Hospital Enrollment and Conversion,” the facility failed to ensure the facility developed/approved/adopted required policies and procedures for a description of the services it furnishes including those furnished through agreement or arrangement; polices for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished; and policies and procedures that address the post-acute care needs of patients receiving services in the Rural Emergency Hospital (REH). Findings Include: During an Entrance Conference, beginning at 1:23 p.m. with the Interim Chief Executive Officer (ICEO), Chief Human Resource Officer (CHR) Emergency Department Director of Nursing (ED DON), Emergency Department Technician Supervisor, and Certified Registered Nurse Anesthetist (CRNA), a request for the facility’s policy and procedures for services it furnishes to include those furnished through agreement or arrangement; polices for the medical management of health problems, consultation or referral, maintenance of health care records, and procedures for the periodic review and evaluation of the services provided and discharge planning. An interview with the Interim Chief Executive Officer on 08/21/2023 at 2:46 p.m. confirmed the facility did not have policy and procedures for services it furnishes, medical management of health problems, consultation or referral, maintenance of health care records, and procedures for the periodic review and evaluation of the services provided and discharge planning. Review of the facility’s “Attestation of Compliance for Rural Emergency Hospital Enrollment and Conversion,” dated and signed by the former CEO at the time of conversion on 09/15/2023, reveals the facility attest to “ ...currently meets and will continue to meet all of the requirements for Rural Emergency Hospitals set forth in the statue and implementing regulations in Subpart E of 42 code of Federal Regulations (CFR) part 485. During exit conference on 08/22/2024 at 12:00 p.m. with an Administration Clerk, Emergency Department Director (EDD), Chief Human Resource Officer (CHRO), Emergency Department Technician Supervisor, and the Interim Chief Executive Officer (ICEO), survey findings were discussed, and no further documentation was submitted for review.”

“Infect prevent & control & antibiotic steward CFR(s): The REH must have active facility-wide programs for the surveillance, prevention, and control of healthcare-associated infections (HAIs) and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic-resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the facility-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 40118 Based on the staff interviews and review of the facility’s “Organizational Chart” the facility failed to establish a facility-wide Infection Prevention and Control Program for the surveillance, prevention and control of healthcare-associated infections and other infectious diseases and the facility also failed to implement an Antibiotic Stewardship Program to optimize the use of antibiotics to ensure the facility follows nationally recognized prevention and control guidelines. Failure to establish and implement and facility wide Infection Prevention and Control Program and an Antibiotic Stewardship Program has the potential to effect the safety and quality of care for all patients presenting to the facility for care and treatment since the facility attested to meeting the requirements for a Rural Emergency Hospital (REH) on 09/15/2023 for four (4) of four (4) days of survey. Findings Include: During an Entrance Conference, on 08/19/2024 beginning at 1:23 p.m. with the Interim Chief Executive Officer (ICEO), Chief Human Resource Officer (CHR) Emergency Department Director of Nursing (ED DON), Emergency Department Technicians Supervisor, and Certified Registered Nurse Anesthetist (CRNA), surveyors requested the facility’s Infection Prevention and Control Plan, Infection Control Committee meeting minutes for the past twelve months or since the facility’s conversion to a Rural Emergency Hospital Facility. The facility failed to present any documentation of an Infection Prevention and Control and Antibiotic Stewardship Program, surveillance data, measurement and analysis of data, or program activities the facility has implemented since the facility’s enrollment and conversion to a REH. An interview on 08/21/2024 at 12:26 p.m. with the Interim Chief Executive Officer (ICEO) concerning documentation of the facility’s Infection Control and Prevention (ICP) Program not provided to the surveyor, confirmed the ICP Program documentation requested does not exist and further confirmed the facility does not have a designated ICP Program Coordinator to implement/manage the program. Review of the facility’s “Organizational Chart,” dated 08/01/2024 reveals no documentation of an Infection Control Program Coordinator. During exit conference on 08/22/2024 at 12:00 p.m. with an Administration Clerk, Emergency Department Director (EDD), Chief Human Resource Officer (CHRO), Emergency Department Technicians Supervisor, and the Interim Chief Executive Officer (ICEO), survey findings were discussed, and no further documentation was submitted for review.”

“Quality assessment & performance improvement CFR(s): The REH must develop, implement, and maintain an effective, ongoing, REH-wide, data-driven quality assessment and performance improvement (QAPI) program. The REH’s governing body must ensure that the program reflects the complexity of the REH’s organization and services; involves all REH departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The REH must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 40118 Based on the staff interviews and review of the facility’s “Organizational Chart.” the facility failed to develop, implement, maintain, and demonstrate an effective ongoing facility-wide data driven Quality Assessment Performance Improvement Program (QAPI), in which the Governing Body ensures the program reflects the complexity of the REH and focuses on improved health outcomes and the prevention/reduction of medical errors. Failure to implement and manage a facility wide QAPI Program has the potential to affect the safety and quality of care for all patients presenting for care and service since the facility attested to meeting the requirements for a Rural Emergency Hospital (REH) on 09/15/2023 for four (4) of four (4) days of survey. Findings Include: During an Entrance Conference, on 08/19/2024 beginning at 1:23 p.m. with the Interim Chief Executive Officer (ICEO), Chief Human Resource Officer (CHR) Emergency Department Director of Nursing (ED DON), Emergency Department Technician Supervisor, and Certified Registered Nurse Anesthetist (CRNA), surveyors requested the facility’s Quality Assessment and Performance Improvement (QAPI) Program’s scope of Improvement Indicators, the facility’s tracking, measurement and analysis of data, and program activities including medical errors and adverse patient events since enrollment and attestation the facility meets all of the requirements of a Rural Emergency Hospital (REH) on 09/15/2024. The facility failed to present any documentation of a QAPI Plan, improvement indicators, measurement and analysis documentation of tracked data or documentation of any program activities the facility has implemented since the facility’s enrollment and conversion to a REH. An interview with the Administration Clerk on 08/21/2024 at 2:33 p.m. confirmed the facility does not have anyone assigned to the tasks for QAPI. The Administration Clerk also confirmed there has been a large volume of staff turn overs in the past year and no one has resumed responsibility as this time. An interview on 08/21/2024 at 12:26 p.m. with the Interim Chief Executive Officer (ICEO) concerning documentation of the facility’s QAPI Program not provided to the surveyor, confirmed the QAPI Program documentation requested does not exist and further confirmed the facility does not have a designated QAPI Coordinator to implement/manage the program. Review of the facility’s “Organizational Chart,” dated 08/01/2024 reveals no documentation of an QAPI Program Coordinator. During exit conference on 08/22/2024 at 12:00 p.m. with an Administration Clerk, Emergency Department Director (EDD), Chief Human Resource Officer (CHRO), Emergency Department Technician Supervisor, and the Interim Chief Executive Officer (ICEO), survey findings were discussed, and no further documentation was submitted for review.”

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 43981 Based on document review and interview, the facility failed provide update the emergency preparedness (EP) plan per requirements of 42 CFR §482.15. Findings Include: On 8/21/24 at 10:40 AM, the facility failed to provide updated (2024) the emergency preparedness (EP) plan. Documentation review revealed the facility provided an EP plan dated from the year of 2023. The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 8/21/24.”

“Medical staff. The governing body must: CFR(s): (3) Ensure that the medical staff has bylaws. This Standard is not met as evidenced by: 45467 Based on Staff interview, document review of the facility’s “Organization Chart,” dated 08/01/2024, “Medical Staff Rules and Regulations,” dated July of 2019, and review of the facility’s “Attestation of Compliance for Rural Emergency Hospital Enrollment and Conversion,” dated 09/15/2023, the facility failed to ensure it has “Medical Staff Bylaws,” and “Medical Staff Rules and Regulations” which have been approved by the Governing Body since enrollment and attestation that the facility meets the requirements for a Rural Emergency Hospital (REH) on 09/15/2023 for four (4) of four (4) days of survey. Findings Include: An interview on 08/22/2024 at 12:02 p.m. with the Interim Chief Executive Officer (ICEO) confirmed the facility has not had a governing body meeting since the facility enrolled and converted to a REH on 09/15/2024 and the ICEO further confirmed there is no documented evidence a Governing Body or an individual legally responsible for the conduct of the REH has been appointed since the enrollment and conversion of the facility. The ICEO confirmed the facility’s “Medical Staff Bylaws,” or “Medical Staff Rules and Regulations” have not been developed/adopted since the conversion to the REH. The only document presented for review was the facility’s “Medical Staff Rules and Regulations” with and original date of July 2019 and no documentation of revision/adoption. Review of the facility’s “Organizational Chart,” dated 08/01/2024 reveals the Interim Chief Executive Officer (ICEO) is the individual designated who oversees the operation of the facility. The “Organizational Chart” shows no documentation of a Governing Body over the Interim CEO. Cross reference to O-140/485.510 additional information. During exit conference on 08/22/2024 at 12:00 p.m. with an Administration Clerk, Emergency Department Director (EDD), Chief Human Resource Officer (CHRO), ER Tech Supervisor, and the Interim Chief Executive Officer (ICEO), survey findings were discussed, and no further documentation was submitted for review.”

“Medical staff. The governing body must: CFR(s): (5) Ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 45467 Based on staff interviews and document review of the facility’s “Organizational Chart” and the facility’s “Attestation of Compliance for Rural Emergency Hospital Enrollment and Conversion,” the facility’s Governing Body or the identified responsible individual who is legally responsible failed to appoint a qualified individual experienced in infectious diseases/antibiotic stewardship and failed to ensure the facility developed, implemented, and maintained an ongoing Rural Emergency Hospital (REH) wide data driven quality assessment and performance improvement (QAPI) program. Failure to implement an Infection Control and QAPI program has the potential to affect the safety and quality of care for all patients presenting to the facility since enrollment and attestation the facility meets the requirements for a REH on 09/15/2023. Findings Include: During an Entrance Conference, on 08/19/2024 beginning at 1:23 p.m. with the Interim Chief Executive Officer (ICEO), Chief Human Resource Officer (CHR) Emergency Department Director of Nursing (ED DON), Emergency Department Technician Supervisor, and Certified Registered Nurse Anesthetist (CRNA), surveyor requested the facility’s Infection Prevention and Control Plan, Infection Control Committee meeting minutes and the facility’s Quality Assessment and Performance Improvement (QAPI) Program’s Scope of Improvement Indicators, the facility’s data tracking, the measurement and analysis, and program activities including medical errors and adverse patient events since enrollment and conversion to a Rural Emergency Hospital Facility. The facility failed to present any documentation of a QAPI Plan, improvement indicators, measurement and analysis documentation of tracked data or documentation of any program activities the facility has implemented since the facility’s enrollment and conversion as a REH. The facility failed to present any documentation of an Infection Prevention and Control and Antibiotic Stewardship Program, surveillance data, measurement and analysis of data, or program activities the facility has implemented since the facility’s enrollment and conversion. An interview on 08/21/2024 at 12:26 p.m. with the Interim Chief Executive Officer (ICEO) confirmed there is no documented evidence the facility has a ICP and QAPI program and they do not have a program coordinator for QAPI or ICP. An interview with the Administration Clerk on 08/21/2024 at 2:33 p.m. confirmed the facility does not have anyone assigned to the tasks for QAPI. The Administration Clerk also confirmed there has been a large volume of staff turn overs in the past year and no one has resumed responsibility as this time. Review of the facility’s “Organizational Chart,” dated 08/01/2024 reveals no documentation of a QAPI Coordinator or an ICP Program Coordinator. Cross reference to O-140/485.510 for additional information. During exit conference on 08/22/2024 at 12:00 p.m. with an Administration Clerk, Emergency Department Director (EDD), Chief Human Resource Officer (CHRO), Emergency Department Technician Supervisor, and the Interim Chief Executive Officer (ICEO), survey findings were discussed, and no further documentation was submitted for review.”

“Contracted Services. CFR(s): (b)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 46164 Based on observation, staff interview, review of the Food Establishment Inspection Report, review of the service agreement between the contracted food services management company and the facility, and email correspondence, the governing body/responsible individual failed to ensure the contracted dietary services for the facility were provided in a safe manner. This had the potential to affect the safety and health of all individuals who were provide food services since the last inspection report expired on 10/13/2020, for three (3) of four (4) days of survey. Findings include: An interview with the Dietary Manager on 08/20/2024 at 10:22 a.m. confirmed the Food Establishment Inspection Report, dated 10/13/2019, is valid for one (1) year. He further confirmed it has been a long time since the last dietary inspection from the state department of health. An interview with the Dietary Manager on 08/20/2024 at 3:06 p.m. confirmed there is no policy for the dietary department available for review. He further confirmed he does not know who is responsible for making sure inspections are done but will contact the state agency to see why food inspections have not been performed since 10/13/2019. An interview with the Interim Chief Executive Officer (ICEO) on 08/21/2024 at 5:05 p.m. confirmed he will have a payment sent to MSDH and request a food services inspection. The ICEO confirms he has only been a part of the facility for about two (2) months and was not aware the dietary department had not had an annual food services inspection. Review of the facility document, “Service Agreement,” between the contracted food services management company and the facility, effective March 1, 2019, reveals, “ ...15. Compliance with Applicable Law ...this provision shall not be construed to require ...” the contracted food services management company “ ...to assume the cost associated with bringing Client into regulatory compliance ...the Client is solely responsible for any cost reporting or other compliance with state or federal agencies under Medicare/Medicaid programs ...”. Review of the facility document from the state agency, “Food Establishment Inspection Report/Permit to Operate”, permit date 10/13/2019, revealed permit valid for one (1) year from the Permit Date. Review of an email provided by the Dietary Manager, dated 8/21/2024 at 1:58 pm from the state agency revealed “ ...According to our audit ...” the facility’s “ ...FOOD PERMIT ...is past due ... for the following years 2021-2023 ...Last permit payment received on this permit was on 11-17-2020 ...”. Cross reference to O-140/485.510 for additional information. During exit conference on 08/22/2024 at 12:00 p.m. with an Administration Clerk, Emergency Department Director, Chief Human Resource Officer, and Emergency Room Technician Supervisor, and Chief Executive Officer, survey findings were discussed, and no further documentation was submitted for review.”

“Compliance with CAH requirements.The REH must CFR(s): (c) The REH must meet the requirements specified in §?485.618, with respect to: (1) 24-hour availability of emergency services (§ 485.618(a)). (2) Equipment, supplies, and medication (§ 485.618(b)). (3) Blood and blood products (§485.618(c)). (4) Personnel (§ 485.618(d)). (5) Coordination with emergency response systems (§ 485.618(e)). This Standard is not met as evidenced by: 40118 Based on observation, staff interviews, email review, and facility invoice review the facility failed to have an operational call light system for 11 out of 11 patient exam rooms in the Emergency Department (ED) and six (6) out of 6 rooms in the Observation Unit. (ED patient care rooms #1 through #11 and Observation Unit patient care rooms #1, #2, #3, #4, #5, #6) Findings Include: During a tour on 08/20/2024 at 10:15 a.m. of the ED with the ED Director, it was observed that 11 of 11 ED patient exam rooms did not have a functional call light system. During a tour on 08/20/2024 at 10:55 a.m. of the Observation Unit with the ED Director it was observed that six (6) of six (6) patient care rooms did not have a functional call light system. An interview on 08/20/2024 at 11:00 a.m. with the ED Director confirmed the call light system was not operational. The ED Director reported the facility was aware the call lights did not work. During an interview on 08/21/2024 at 10:33 a.m. with the ED Tech Supervisor it was confirmed the facility does not have a policy for the call light system. The ED Tech Supervisor also confirmed the call light system is not working at this time. An interview on 08/21/2024 at 4:28 p.m. with the Interim Chief Executive Officer (ICEO), confirmed he was aware the call light system was not operational. The ICEO reported a new system was purchased, but he has been unable to find anyone to install it. The ICEO reported the past due invoice had been paid for the call light system but could not show proof of payment. Review of an email from the former Director of Clinical Operations to the ED Director dated June 14, 2024, revealed “ ...These changes will take effect after the following have been addressed: 1. Call light system purchased and installed (purchased-need installation estimate) ...” Review of invoice from medical device company reveals the invoice was noted past due on 06/13/2024 for a call light system. During exit conference on 08/22/2024 at 12:00 p.m. with an Administration Clerk, Emergency Department Director (EDD), Chief Human Resource Officer (CHRO), ER Tech Supervisor, and the Interim Chief Executive Officer (ICEO), survey findings were discussed, and no further documentation was submitted for review.”