Phillips County Hospital - Cah

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [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: 41652 Based on interview, record review, and policy review, the hospital failed to comply with the conditions of participation outlined at 42 CFR §489.20 and related requirements at §489.24 (refer to Appendix V). The hospital failed to provide an appropriate MSE (medical screening exam) by a qualified medical provider within the capability of the hospital ED (Emergency Department) to determine whether or not an EMC (Emergency Medical Condition) existed for 1 (#16); failed to obtain written patient consent for transfer for 2 (#s 5 and 17); failed to consult an MD/DO when transferring an unstable patient for 1 (#10); failed to obtain a co-signature of an MD/DO on the transfer certification for 1 (#10); and failed to provide pertinent medical records to the receiving hospital for 1 (#10) of 20 sampled patients. Findings include: 1. Review of the hospital policy titled, “EMTALA,” dated 1/22/25, showed: “PCH [Phillips County Medical Center] shall comply with all regulations and requirements of EMTALA. An EMTALA obligation is triggered when an individual presents to the ED and: 1. Requests examination or treatment for a medical condition independently or via representative acting on their behalf ... This policy applies to PCH campus including any department within the hospital and PCH property within 250 yards of the hospital (parking lots, sidewalks) and is intended for any persons who present to PCH seeking emergency care ...” During an interview on 12/29/25 at 1:08 p.m., staff member H stated NF1 brought patient #16 to the clinic for an appointment. Staff member H stated NF1 told her about an incident at the hospital during the evening of 6/21/25. Staff member H stated NF1 told her that when the patient presented to the hospital, the hospital did not check the patient’s vital signs, did not examine the patient, and did not do any laboratory tests. (Refer to C-2406) 2. Review of the hospital policy titled, “EMTALA,” dated 1/22/25, showed a person is considered stabilized and appropriate for transfer if: “... the woman has delivered the child and the placenta ...” The policy failed to show that a stabilized patient requiring a higher level of care required documented acknowledgement of the risks and benefits of transfer and signed consent to the transfer. Review of patient #5 and #17’s ED records, showed the patients presented to the hospital with emergency medical conditions, were stabilized within the capability of the hospital, and then transferred to another facility to receive a higher level of care. The physician certifications of transfer failed to contain the patient’s acknowledgment of understanding the risks and benefits, and consent to the transfer. (Refer to C-2409) 3. Review of the hospital policy titled, “EMTALA,” dated 1/22/25, showed an unstabilized patient will not be transferred unless, “... a provider has signed a certification (PCH Transfer Sheet form) that, based upon the information available at the time of transfer, the medical benefits reasonable [sic] expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risk to the patient ...from being transferred”, and, “If a provider is not physically present, a qualified medical person consults with the provider and certifies in writing ... that the benefits of discharge or transfer outweigh the risks. The provider must subsequently co-sign the certification.” The policy also showed, “... A transfer is appropriate if: PCH ...sends copies of all medical records related to the EMC for which the individual presented that are available at the time of transfer.” The policy failed to provide guidance for situations involving an unstable patient needing to be transferred. Review of patient #10’s record showed the ED provider documented the patient’s condition was guarded. The transfer certification, signed by the ED provider (mid-level provider) did not have the co-signature of the MD/DO consulted regarding the transfer and did not show what medical records were sent to the receiving facility. (Refer to C-2409)”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [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: 46400 Based on interview, record review, and policy review, the hospital failed to maintain a central log which included all patients who presented to the facility seeking emergency care, whether the patient refused or was refused treatment, admitted and treated, stabilized and transferred, or discharged, for 1 (#16) patient of 20 sampled patient records reviewed. Findings included: During an interview on 2/25/26 at 10:30 a.m., NF2 stated patient #16 was brought to the hospital on 6/21/25 at 9:30 p.m., she was having pain. NF2 stated the patient had dementia and did not express herself well. The family requested patient #16 be taken to the ED for evaluation. The family and the aide transported patient #16 through the door connecting the assisted living facility to the hospital. They were stopped at the nurse’s station and questioned by staff member C (ED provider). Staff member C asked the family, “What do you want me to do? Do you want her to die at home or the hospital?” NF2 stated it was reported to her that the hospital did not check patient #16’s vital signs or perform an examination prior to patient #16 being returned to the assisted living facility. NF2 stated it was reported the provider told patient #16 and an unidentified family member, the provider and hospital could not do anything further for patient #16. NF2 stated patient #16 spent approximately one hour at the nurse’s station discussing her condition with the provider and family member. NF2 stated the provider walked back to the assisted living facility with patient #16 and the family. During an interview on 12/29/25 at 1:08 p.m., staff member H stated patient #16 had Alzheimer’s disease and lived in the assisted living facility attached to the hospital. Staff member H stated patient #16 was brought to the ED on the evening of June 21, 2025. Before she could be registered to be seen in the ED, staff member H stated the ED provider [staff member C] said patient #16 was a DNR and there was not a whole lot they could do for her as she was at baseline. Review of the hospital’s ED log did not show patient #16 registered on June 21, 2025.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (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: 46400 Based on interview, record review, and policy review, the hospital failed to provide an appropriate MSE (medical screening exam) by a qualified medical provider within the capability of the hospital ED (Emergency Department) to determine whether or not an EMC (Emergency Medical Condition) existed for 1 (#16) of 20 sampled patients. Findings include: During an interview on 2/25/26 at 10:30 a.m., NF2 stated patient #16 was brought to the hospital on 6/21/25 at 9:30 p.m., she was having pain. NF2 stated the patient had dementia and did not express herself well. The family requested patient #16 be taken to the ED for evaluation. The family and the aide transported patient #16 through the door connecting the assisted living facility to the hospital. They were stopped at the nurse’s station and questioned by staff member C (ED provider). Staff member C asked the family, “What do you want me to do? Do you want her to die at home or the hospital?” NF2 stated it was reported to her that the hospital did not check patient #16’s vital signs or perform an examination prior to patient #16 being returned to the assisted living facility. NF2 stated it was reported, the provider told patient #16 and an unidentified family member, the provider and hospital could not do anything further for patient #16. NF2 stated patient #16 spent approximately one hour at the nurse’s station discussing her condition with the provider and family member. NF2 stated the provider walked back to the assisted living facility with patient #16 and the family. During an interview on 12/29/25 at 1:08 p.m., staff member H stated NF1 brought patient #16 to the clinic for an appointment. Staff member H stated NF1 told her about an incident at the hospital during the evening of 6/21/25. Staff member H stated NF1 told her a family member brought patient #16 to the ED, but before patient #16 could be checked into the ED to be seen, the ED provider [staff member C] stated patient #16 was a DNR and there was not a whole lot they (the hospital) could do for patient #16 as she was at her baseline. Staff member H stated NF1 told her the hospital did not check the patient’s vital signs, did not examine the patient, and did not do any laboratory tests. Staff member H stated NF1 was very upset that patient #16 did not receive and examination. During an interview on 12/31/25 at 11:05 a.m., staff member C stated many conversations with patient #16’s family had occurred about limited interventions for her care and the possibility of stopping some of her medications. Staff member C stated patient #16 was “very demented.” Staff member C stated patient #16 had, “... come in a lot over the years,” and had been, “... treated for UTIs and lots of other things over the years.” Staff member C was unable to remember providing care for resident #16 on 6/21/25. Review of the hospital on call provider schedule for June 2025 showed staff member C as the on-call provider for the hospital ED on 6/21/25. Review of the hospital ED log did not show patient #16 registered on 6/21/25. Review of the hospital policy titled, “EMTALA,” dated 1/22/25, showed: “PCH shall comply will all regulations and requirements of EMTALA. An EMTALA obligation is triggered when an individual presents to the ED and: 1. Requests examination or treatment for a medical condition independently or via representative acting on their behalf ... This policy applies to PCH campus including any department within the hospital and PCH property within 250 yards of the hospital (parking lots, sidewalks) and is intended for any persons who present to PCH seeking emergency care ...””

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1-2) (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: 41652 Based on interview, record review, and policy review, the hospital failed to obtain a written patient consent for transfer and include a summary of the risks and benefits of transfer for 2 (#s 5 and 17); failed to consult an MD/DO when transferring an unstable patient for 1 (#10); failed to obtain a co-signature of an MD/DO on the transfer certification for 1 (#10); and failed to provide pertinent medical records to the receiving facility for 1 (#10) of 20 sampled patients. Findings include: 1. Review of patient #5’s ED record, showed she presented to the ED on 11/23/25 at 9:54 a.m. with a four-day history of uterine contractions, with increased symptoms over the past day. The decision was made, by a mid-level provider, to transfer patient #5 to a facility which was able to provide a higher level of care for obstetric and newborn patients. While awaiting arrival of the flight crew (transfer was initially planned via air), patient #5 continued to have contractions. Once the flight crew arrived, a pelvic examination was performed. The examination showed patient #5 was fully dilated and effaced and was ready to deliver. The infant was delivered at 2:42 p.m. on 11/23/25. The provider (staff member F) decided to transfer patient #5 and the infant to the closest facility which provided obstetric and newborn care. The transfer certification, completed by staff member F, did not contain the patient’s written consent or the acknowledgment of understanding of the risks and benefits associated with the transfer. During an interview on 12/31/25 at 10:00 a.m., staff member F stated he remembered completing the transfer certification form for patient #5. He stated he did not remember getting patient #5’s consent (signature) or her acknowledgment of the risks and benefits of the transfer. Review of the hospital policy titled, “EMTALA,” dated 1/22/25, showed a person is considered stabilized and appropriate for transfer if, “... the woman has delivered the child and the placenta ...” The policy does not specify the patient needs to consent to the transfer and acknowledge understanding of the risks and benefits of the transfer. 2. Review of patient #17’s ED record, showed patient #17 presented via ambulance to the hospital’s ED on 5/20/25 at 8:20 p.m. Results documented in the physician’s note showed patient #17 met criteria for severe DKA (diabetic ketoacidosis: a life threatening diabetes emergency). It was determined by the physician that patient #17 needed a higher level of care, to include ICU admission. Transfer to Hospital B was initiated. Patient #17 left the hospital via helicopter at 12:27 a.m. The physician certification for transfer lacked patient or patient representative acknowledgement of the risks/benefits and consent to transfer, despite the patient and patient’s family member being alert and present. During an interview on 12/30/25 at 2:00 p.m., staff member B stated when a patient was transferred to a higher level of care the provider was responsible for completing the transfer form. During an interview on 12/31/25 at 10:45 a.m., staff member E stated it was ultimately up to the provider to go over risks and benefits and get the signed consent for transfer. If the patient was unable to sign or unconscious nursing would cosign as a witness. 3. Review of patient #10’s EHR, dated 3/15/25 at 5:32 a.m., showed the patient presented to the ED via ambulance after sustaining a fall at home. Review of patient #10’s ED provider note, showed, “Assessment: The patient’s main Clint plaint (complaint) on arrival is shortness of breath... Due to his recent hospitalization for pneumonia, this is more likely a respiratory illness process... His lactate is 9.9 (elevated) and his pressures (blood pressure) are low ... Plan: ...He will be transported to [hospital C] via stat air ambulance services. ...” [sic]. The provider note also showed patient #10’s condition at the time of transfer was guarded. The note failed to show staff member C (mid-level provider) consulted with staff member D (supervising MD/DO) regarding the appropriateness of the transfer . Review of patient #10’s Transfer Sheet, dated 3/15/25, signed by staff member C, showed the patient was being transferred to Hospital C. The form failed to identify the type of transfer (emergent or non-emergent), the mode of transfer (air, ground, other), and the pertinent medical records sent with the patient. The form did not include the co-signature of the physician (staff member D) who should have been consulted regarding the transfer. During an interview on 12/31/25 at 11:00 a.m., staff member C stated she did not automatically notify the supervising physician when an unstable patient required transfer for a higher level of care. During an interview on 12/31/25 at 11:55 a.m., staff member D stated she was responsible for providing medical oversight to the mid-level providers in the ED. Staff member D stated she was new to the role of Medical Director and was unaware of the requirement for mid-level providers to consult an MD/DO when an unstable patient needed to be transferred emergently. She also was unaware she was required to co-sign the transfer certification for these patients. Review of the hospital policy titled, “EMTALA,” dated 1/22/25, showed an unstabilized patient will not be transferred unless, “... a provider has signed a certification (PCH Transfer Sheet form) that, based upon the information available at the time of transfer, the medical benefits reasonable [sic] expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risk to the patient ...from being transferred”, and, “If a provider is not physically present, a qualified medical person consults with the provider and certifies in writing ... that the benefits of discharge or transfer outweigh the risks. The provider must subsequently co-sign the certification.” The policy also showed, “... A transfer is appropriate if: PCH ...sends copies of all medical records related to the EMC for which the individual presented that are available at the time of transfer.” The policy failed to provide guidance for situations involving an unstable patient needing to be transferred and failed to identify a MD/DO must be consulted for the transfer and co-sign the transfer certification. 46400”

“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: 40068 Based on record review and interview, the facility failed to plan and implement a provision of subsistence needs for the staff and the patients, whether they evacuated or sheltered in place. This affects all occupants in the facility. Findings include: Review of the EP plan, policies, and procedures on 8/5/24, showed the facility lacked a complete system for determining subsistence needs for staff and patients. Specific needs for pharmaceutical supplies, alternate sources of energy to maintain temperatures, and emergency lighting for the number of patients and staff who would be sheltering in place was not addressed. During an interview on 8/5/24 at 4:00 p.m. staff member A stated the emergency preparedness plan did not have specific information regarding pharmaceutical supplies, or alternate sources of energy the facility would utilize in an emergency.”

“Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 485.623(d) for Critical Access Hospitals (CAHs), a life safety code survey was performed on 8/5/24. Under this regulatory requirement, the facility must meet the applicable provisions of the National Fire Protection Associations (NFPA) 101 Life Safety Code, 2012 Edition, and those mandatory Codes referenced by that edition. The facility was surveyed specifically using Chapter 19 Existing Health Care Occupancies of NFPA 101. The building construction type was found to be Type V (111) according to architect plans reviewed at the facility and State Agency initial inspection records. The building contains 3 smoke compartments, and 1 basement smoke compartment. No new construction has occured since the last survey on 6/18/19. The CAH is separated with 2 hour barriers from the Rural Health Clinic (RHC) and Long Term Care Facility. There is a horizontal exit through the RHC 2 hour barrier that was reviewed as part of the egress for the CAH. Therapy services is located in the basement of the building therefore it was surveyed. These requirements were not met as evidenced by the following deficiencies:”

“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: 40068 Based on observation, interview and record review the facility failed to: a) maintain the sprinkler system in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Table 5.1.1.2., b) failed to ensure sprinkler piping was fee from external loads in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2., and c) maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.6.1. These deficiencies affected all smoke compartments in the facility. Findings include: 1. Review of the facility’s quarterly sprinkler inspections showed a sprinkler inspection was not completed for the first quarter of 2024 (January - March). During an interview on 8/5/24 at 2:15 p.m., staff member B stated the sprinkler company did not complete an inspection for the first quarter of 2024. Staff member B stated they rescheduled. 2. During an observation on 8/5/24 at 1:16 p.m., the basement storage room was inspected. Multiple cords were observed resting on the sprinkler piping. 3. During an observation on 8/5/24 at 2:00 p.m., the PT storage closet was inspected. There was storage within 18 inches of the sprinkler head.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 40068 Based on an observation, the facility failed to maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1. This deficiency affected 1 of 1 basement smoke compartments in the facility. Findings include: During an observation at 8/5/24 at 1:29 p.m., the area in front of the purchasing basement was inspected. A portable fire extinguisher was observed, blocked by storage of various items.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 40068 Based on observation, the facility failed to maintain corridor door openings in accordance with NFPA 101, 2012 Edition, Section 19.3.6.3.10. This deficiency affected 1 out of 1 basement smoke compartments in the facility. Findings include: 1. During an observation on 8/5/24 at 1:25 p.m., the IT room door was inspected. The corridor door was held open by a wedge. 2. During an observation on 8/5/24 at 1:26 p.m., the conference room door was inspected. The corridor door was held open by a wedge.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 40068 Based on observation, the facility failed to maintain electrical rooms with sufficient working space around electrical panels in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-26 (E) (1) (a) through (E) (1) (d). This deficiency affected 1 out of 1 basement smoke compartment in the facility. Findings include: During an observation on 8/5/24 at 1:30 p.m., the purchasing office was inspected. There was a cart stored in front of the electrical panel.”

“STAFFING AND STAFF RESPONSIBILITIES CFR(s): §485.631 Condition of Participation: Staffing and Staff Responsibilities This Condition is not met as evidenced by: 47752 Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Staffing and Staff responsibilities. Based on interview and record review the facility failed to: -Ensure the physician in conjunction with the mid-level providers, periodically reviewed patient records. This deficient practice had the potential to affect all patients receiving care in the facility. (See C0985). - Ensured a Doctor of Medicine or Osteopathy signed the records for all inpatients cared for by Nurse Practitioners or Physician Assistants. This deficient practice had the potential to affect the quality of care for all patients admitted to the facility. (See 0986). -Ensure a Doctor of Medicine or Osteopathy was available though direct radio or telephone communication or electronic communication for consultation, assistance with medical emergencies, or patient referral. This deficient practice had the potential to affect the quality of care of all patients who sought care at the facility. (See C0988). -Ensure a process was in place for Nurse Practitioners and Physicians Assistants to notify a Doctor of Medicine or Osteopathy when an inpatient admission occurred. This deficient practice had the potential to affect the quality of care for patients admitted to the facility. (See C998). -Ensure a process was in place for periodic performance evaluations of Nurse Practitioners and Physician Assistants by a Doctor of medicine or Osteopathy. This deficient practice had to the potential to affect all patients receiving care in the facility by a Nurse Practitioner or Physician Assistant. (See C0999).”

“INFECTION PREVENT & CONTROL & ABT STEWAR PROG CFR(s): The CAH must have active facility-wide programs, for the surveillance, prevention, and control of 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 coordination with the facility-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 47752 Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Infection Prevention and Control. Based on interview and record review the facility failed to: -Ensure the individual employed as the Infection Prevention and Control Specialist was qualified through education, training, experience and/or certification in infection prevention and control practices. This deficient practice had the potential to affect all patients receiving care and staff providing care at the facility. (See C1204). - Ensure specific surveillance, tracking, and trending of infections were established for the Infection Prevention and Control Program. This deficient practice had the potential to affect all patients receiving care within the facility. (See C 1208). -Ensure the facility had a system in place for active surveillance, prevention, and control of all infections, to include antibiotic use. This deficient practice had the potential to affect all patients and staff within the facility. (See C1225). -Ensure the facility integrated all Healthcare Associated Infections, Antibiotic Stewardship, and other infectious diseases through the facilities QAPI leadership and program. This deficient practice had the potential to affect all patients receiving care at the facility. (See C1229). -Ensure complete documentation of the infection prevention and control program, to include surveillance, and tracking of infections. This deficient practice had the potential to affect all patients and staff within the facility. (See C1235). -Ensure the individuals employed as the Infection Prevention and Control Specialists provided competency-based training and education to all personnel and staff, including medical staff, on the practical applications of antibiotic stewardship guidelines, policies, and procedures. (See C1250).”

“PERSONNEL CFR(s): (1) Except as specified in paragraph (d)(3) of this section, there must be a doctor of medicine or osteopathy, a physician assistant, a nurse practitioner or a clinical nurse specialist with training or experience in emergency care on call and immediately available by telephone or radio contact, and available on site within the following timeframes: (i) Within 30 minutes, on a 24-hour a day basis, if the CAH is located in an area other than an area described in paragraph (d)(1)(ii) of this section; or (ii) Within 60 minutes, on a 24-hour a day basis, if all of the following requirements are met: (A) The CAH is located in an area designated as a frontier area (that is, an area with fewer than six residents per square mile based on the latest population data published by the Bureau of the Census) or in an area that meets criteria for a remote location adopted by the State in its rural health care plan, and approved by CMS, under section 1820(b) of the Act. (B) The State has determined under criteria in its rural health care plan, that allowing an emergency response time longer than 30 minutes is the only feasible method of providing emergency care to residents of the area served by the CAH. (C) The State maintains documentation showing that the response time of up to 60 minutes at a particular CAH it designates is justified because other available alternatives would increase the time needed to stabilize a patient in an emergency. (2) A registered nurse with training and experience in emergency care can be utilized to conduct specific medical screening examinations only if- (i) The registered nurse is on site and immediately available at the CAH when a patient requests medical care; and (ii) The nature of the patient’s request for medical care is within the scope of practice of a registered nurse and consistent with applicable State laws and the CAH’s bylaws or rules and regulations. (3) A registered nurse satisfies the personnel requirement specified in paragraph (d)(1) of this section for a temporary period if-- (i) The CAH has no greater than 10 beds; (ii) The CAH is located in an area designated as a frontier area or remote location as described in paragraph (d)(1)(ii)(A) of this section; (iii) The State in which the CAH is located submits a letter to CMS signed by the Governor, following consultation on the issue of using RNs on a temporary basis as part of their State rural health care plan with the State Boards of Medicine and Nursing, and in accordance with State law, requesting that a registered nurse with training and experience in emergency care be included in the list of personnel specified in paragraph (d)(1) of this section. The letter from the Governor must attest that he or she has consulted with State Boards of Medicine and Nursing about issues related to access to and the quality of emergency services in the States. The letter from the Governor must also describe the circumstances and duration of the temporary request to include the registered nurses on the list of personnel specified in paragraph (d)(1) of this section; (iv) Once a Governor submits a letter, as specified in paragraph (d)(3)(iii) of this section, a CAH must submit documentation to the State survey agency demonstrating that it has been unable, due to the shortage of such personnel in the area, to provide adequate coverage as specified in this paragraph (d). (4) The request, as specified in paragraph (d)(3)(iii) of this section, and the withdrawal of the request, may be submitted to us at any time, and are effective upon submission. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure staff had current certifications required to care for patients in the emergency department. This deficient practice had the potential to affect the quality of care for all patients who received care in the emergency department. Findings include: Review of staff member C’s personnel record showed she was a contracted staff with the facility on 7/2/24. Staff member C worked in the emergency department. Staff member C did not have a current PALS (Pediatric Advanced Life Support) certification and review of her personnel file showed her PALS certification had expired in 6/2024. Review of staff member S’s personnel record showed she was hired on 12/22/22. Staff member S worked in the emergency department. Staff member S did not have an ACLS (Advanced Cardiac Life Support) certification on file. During an interview on 7/30/24 at 2:58 p.m., staff member B stated she kept a file with all the licenses and certifications for facility staff. During an interview on 7/31/24 at 10:01 a.m., staff member B stated she knew there were some staff members who did not have current certifications. Staff member B stated she used a spreadsheet to track when licenses or certifications expired. Staff member B stated she had been working with different facilities to set up a class for staff with expired certifications, but had been, “Struggling to get it done.” Review of a facility document titled, “Job Classification, Registered Nurse,” undated showed: ... “Licensure/Certification: State of Montana Nursing license, Certified in ACLS- Advanced Cardiac Life Support, PALS- Pediatric Advanced Life Support ... ... 33. Must maintain and or attain BLS, ACLS, PALS...or other certifications as may be requested or required by [Facility Name] to provide safe quality patient care.””

“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: 35356 Based on observation, interview, and record review, the facility failed to establish policy and procedures for the safe utilization of space heaters in the facility and failed to ensure FSC was observed while using space heaters in the facility ¹. This deficient practice had the potential to affect all patients and staff utilizing the tub room in the facility. Findings include: During an observation on 7/29/24 at 2:45 p.m., there was an unplugged Comfort Zone brand space heater observed in the facility’s tub room, room number 152. The space heater did not have a thermostat which specified the heating element on the device did not exceed 212 degrees Fahrenheit. During an interview on 7/30/24 at 12:10 p.m., staff member W stated the space heater should not be in the tub room at all. She stated the space heater may be being brought in by another staff member who feels the tub room does not get warm enough when providing baths for patients. During an interview and record review on 7/30/24 at 12:10 p.m., a facility document request was submitted for the policy and procedure for space heater use in the facility. Staff member W stated the facility did not have a policy or procedure for the use of space heaters in the facility. ¹ Actual Code: NFPA 101, 2012 Edition, Section 19.7.8: Portable space heating devices are prohibited in health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212 degrees Fahrenheit. If a facility is utilizing space heaters, the facility must maintain documentation/policies consistent with the Life Safety Code.”

“PATIENT SERVICES CFR(s): In conjunction with the physician assistant and/or nurse practitioner members, periodically reviews the CAH’S patient records, provides medical orders, and provides medical care services to the patients of the CAH; and This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure the physician in conjunction with the mid-level providers, periodically reviewed patient records. This deficient practice had the potential to affect all patients receiving care in the facility. Findings include: During an interview on 7/31/24 at 10:00 a.m., staff member H stated she had only been working at the facility since March of 2024. Staff member H stated, “I don’t know what the process for periodic review of patient records is, I just started looking at them.” (Patient Records). Review of a facility document titled, “Medical Staff Rules and Regulations,” with a revision date of 11/20/24, showed: ... “9. Physician Review. The supervising Physician must review and sign the records of each patient admitted and treated by a Physician Assistant or Nurse Practitioner...”. Review of a facility document titled, “Medical Director/Chief of Staff Overview,” undated, showed: ... “a. In conjunction with ... physician assistants and or APRN’s, periodically review the Hospital’s patient records, ...” [sic]”

“PATIENT CARE SERVICES CFR(s): [The doctor of medicine or osteopathy-] (iv) Periodically reviews and signs the records of all inpatients cared for by nurse practitioners, clinical nurse specialists, or physician assistants. (v) Periodically reviews and signs a sample of outpatient records of patients cared for by nurse practitioners, clinical nurse specialists, certified nurse midwives, or physician assistants only to the extent required under State law where State law requires record reviews or co signatures, or both, by a collaborating physician. This Standard is not met as evidenced by: 47752 Based on interview and record review the facility failed to have a process which ensured a Doctor of Medicine or Osteopathy signed the records for all inpatients cared for by Nurse Practitioners or Physician Assistants. This deficient practice had the potential to affect the quality of care for all patients admitted to the facility. Findings include: During an interview on 7/31/24 at 10:00 a.m., Staff member H stated she had not been reviewing inpatient records of patients who were admitted by Nurse Practitioners or Physician Assistants. Staff member H stated, “I am supposed to, but I have not done it yet.” Review of a facility document titled, “[Facility Name] Medical Staff Bylaws,” dated October 2023, showed: ... “C. Medical Direction and Oversight... ... b. ...reviews and signs the records ... of each inpatient admitted and treated in the Hospital by APRN’s and PA’s ...””

“RESPONSIBILITIES OF MD OR DO CFR(s): A doctor of medicine or osteopathy is present for sufficient periods of time to provide medical direction, consultation, and supervision for the services provided in the CAH, and is available through direct radio or telephone communication or electronic communication for consultation, assistance with medical emergencies, or patient referral. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure a Doctor of Medicine or Osteopathy was available through direct radio or telephone communication or electronic communication for consultation, assistance with medical emergencies, or patient referral. This deficient practice had the potential to affect the quality of care of all patients who received care at the facility. Findings include: During an interview on 7/31/24 at 10:00 a.m., staff member H stated she was the facility physician who was available at all times. Staff member H stated she was on-call 24 hours a day, seven days a week, unless she was out of service. Staff member H stated there was no alternate physician coverage if she was, “Out of range.” Review of a facility document titled, “[Facility Name] Medical Staff Bylaws,” dated October 2023, showed: ... “C. Medical Direction and Oversight 1. The Medical staff shall ensure that a Physician Member at all times is available and responsible to provide medical direction for the Hospital’s health care activities ... a Physician member shall be available to provide healthcare services to the patients in the Hospital, wherever needed and requested. ... e. ... and is available by radio, telephone or electronic communication for consultation, assistance with medical emergencies and patient referrals.” [sic]”

“PA, NP, & CLINICAL SPEC RESPONSIBILITIES CFR(s): Whenever a patient is admitted to the CAH by a nurse practitioner, physician assistant, or clinical nurse specialist, a doctor of medicine or osteopathy on the staff of the CAH is notified of the admission. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to have a process in place to ensure Nurse Practitioners and Physicians Assistants notified a Doctor of Medicine or Osteopathy when an inpatient admission occurred for 6 (#s 7, 11, 14, 15, 18, and 19) of 20 sampled patients. This deficient practice had the potential to affect the quality of care for patients admitted to the facility. Findings include: During an interview on 7/31/24 at 10:00 a.m., staff member H stated she was not notified of all inpatient admissions and is not sure what the facility process was. Review of the following medical records failed to show the Nurse Practitioner, or the Physician Assistant, notified the physician of the admission to of a patient to inpatient status. - Patient #7, admitted on 4/16/24, discharged on 4/18/24, - Patient #11, admitted on 11/24/23, discharged on 11/24/23, - Patient #14, admitted on 2/15/24, discharged on 2/21/24, - Patient # 15, admitted on 7/25/23, discharged on 8/4/24, - Patient #18, admitted on 8/3/23, discharged on 8/6/23, and - Patient #19, admitted on 3/5/24, discharged on 3/8/24. Review of a facility document titled, “Medical Staff Rules and Regulations,” with a revision date of 11/20/24, showed: ... “5. Physician Notification. Whenever a patient is admitted to the Hopital by a Physician Assistant or Nurse Practitioner, a supervising Physician must be notified... within 24 hours after the admission and a written notification of the consultation and of the Physician’s approval or disapproval must me kept in the patient’s record.””

“PERIODIC REVIEW OF CLINICAL PRIVILEGES CFR(s): §485.631(d) Standard: Periodic review of clinical privileges and performance. The CAH requires that- (1) The quality and appropriateness of the diagnosis and treatment furnished by nurse practitioners, clinical nurse specialist, and physician assistants at the CAH are evaluated by a member of the CAH staff who is a doctor of medicine or osteopathy or by another doctor of medicine or osteopathy under contract with the CAH. (2) The quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH are evaluated by- (i) One hospital that is a member of the network, when applicable; (ii) One Quality Improvement Organization (QIO) or equivalent entity; (iii) One other appropriate and qualified entity identified in the State rural health care plan; (iv) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH’s patient under an agreement between the CAH and a distant-site hospital, the distant-site hospital; or (v) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH’s patients under a written agreement between the CAH and a distant-site telemedicine entity, one of the entities listed in paragraphs (d)(2)(i) through (iii) of this section. (3) The CAH staff consider the findings of the evaluation and make the necessary changes as specified in paragraphs (b) through (d) of this section. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure a process was in place for periodic performance evaluations of Nurse Practitioners and Physician Assistants by a Doctor of Medicine or Osteopathy. This deficient practice had to the potential to affect all patients receiving care in the facility by a Nurse Practitioner or Physician Assistant. Findings include: Review of a credentialing file for staff member J showed no periodic reappraisal had been completed. Review of a credentialing file for staff member N showed no periodic reappraisal had been completed. During an interview on 7/31/24 at 10:00 a.m., staff member H stated she was not aware of any process for periodic evaluation of clinical privileges and had not done any periodic evaluations of facility Nurse Practitioners and/or Physician Assistants.”

“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: 35356 Based on observation, interview, and record review, the facility failed to ensure current and accurate records are kept of the receipt and disposition of all scheduled drugs; and failed to develop and implement patient care policies and procedures which addressed the storage, handling, dispensing, and administration of drugs and biologicals with the facility. This deficient practice had the potential to affect all patients receiving pharmaceutical services. Findings include: 1. Accurate Records of Scheduled Drugs A. Fentanyl Patches During an observation on 7/30/24 at 9:30 a.m., the narcotic logbook showed a count of nine, 100 mcg Fentanyl patches for patient #4. An observation of the actual package of Fentanyl, which was secured in the lock box, showed a count of four patches. The pharmacy label showed a count of 10 patches; there was only one box of five patches found in the lock box. During an interview on 7/30/24 at 10:15 a.m., staff member R stated the family had brought in patient #4’s Fentanyl patches from home. She stated they only brought in one box of patches which was not opened. Staff member R stated when she logged the patches in with her co-worker, she only looked at the pharmacy label on the box of Fentanyl patches and assumed there were 10 patches in the box since that was what the pharmacy label showed. Staff member R said she did not read the box itself or open the box to count the number of patches. She stated that could explain why the narcotic logbook showed a count of nine patches and the actual count of Fentanyl patches was only four. She stated it was the expectation when logging in a patient’s scheduled medications into the logbook there were two nursing staff to verify the count. B. Liquid Morphine Sulfate During an observation on 7/30/24 at 9:30 a.m., the Narcotic Log showed Liquid Morphine was available for patient #1. The box which contained the liquid morphine showed two separate labels for two separate patients. The first label was printed from a pharmacy which showed the medication was issued to patient #1. The second label was printed by the facility and was placed on the box of liquid morphine and had patient #4’s identifying information listed. During an interview on 7/30/24 at 10:00 a.m., staff member S stated she had asked another staff member to print her patient identification label for patient #1 so she could put it on the box of morphine for patient #1. Staff member S admitted she did not verify the name on the label she placed on the box of morphine for patient #1 and did not realize that it was a label for patient #4. Staff member S stated it was important to verify the information with a second nurse when logging in new scheduled medications for patients. During an interview on 7/30/24 at 10:15 a.m., staff members B and I stated it was the expectation that all scheduled medications were logged into the Narcotic Logbook with a double count with a two-nurse verification, and the expectation that the narcotic count would be accurate for what was in the lock box in addition to what was on the Narcotic Log. They stated it was also important that the correct patient identifiers were placed on the appropriate medications. 2. Development and Implementation of Medication Policy and Procedures A review of the facility’s policy and procedures for Medication Administration failed to address the storage, handling, dispensing, and administration of drugs and biologicals, including policy and procedures for the receipt, storage, and dispensing of scheduled medications.”

“RECORDS SYSTEM CFR(s): Reports of physical examinations, diagnostic and laboratory test results, including clinical laboratory services, and consultative findings; This Standard is not met as evidenced by: 35356 Based on interview and record review, the facility failed to ensure a physician co-signed the history and physical for acute inpatient admissions for 10 (#s 1, 5, 6, 7, 9, 10, 11, 15, 18, and 19) of 20 sampled patients who were admitted to the hospital. This deficient practice had the potential to affect all patients admitted to the hospital. Findings include: Review of the following patient medical charts showed there was no physician co-signature noted on the admission history and physical completed by the mid-level practitioners for: - patient #1, admitted on 7/26/24, - patient #5, admitted on 4/3/24, - patient #6, admitted on 6/14/24, - patient #7, admitted on 4/16/24, - patient #9, admitted on 12/4/23, - patient #10, admitted on 10/30/23, - patient #11, admitted on 11/24/23, - patient #15, admitted on 7/25/23, - patient #18, admitted on 8/3/23, and - patient #19, admitted on 3/5/24. During an interview on 7/31/24 at 10:00 a.m., staff member A stated they were not aware a physician needed to co-sign all admitting mid-level practitioners’ history and physicals for patients, assuming full responsibility of the patients care. Staff member A stated they only notified the provider when a mid-level practitioner admitted a patient to acute care services. During an interview on 7/31/24 at 10:00 a.m., staff member H stated she had not been reviewing inpatient records of patients who were admitted by Nurse Practitioners or Physician Assistants. Staff member H stated, “I am supposed to, but I have not done it yet.” A document request for the facility’s policy and procedure for a physician co-signature of the history and physical for acute inpatient admissions was requested on 7/31/24 at 10:00 a.m. No additional documentation was received by the end of the survey. 47752”

“INFECTION PREVENT & CONTROL ORG & POLICIES CFR(s): Infection prevention and control program organization and policies. The CAH must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body, or responsible individual, as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure the individual employed as the Infection Prevention and Control Specialist was qualified through education, training, experience and/or certification in infection prevention and control practices. This deficient practice had the potential to affect all patients receiving care and staff providing care at the facility. Findings include: During an interview on 7/30/24 at 3:30 p.m., staff member I stated she was appointed as the Infection Preventionist about a year and a half ago. Staff member I stated she had no education or certification in Infection Prevention. Staff member I stated she had been learning as she went and had joined APIC (Association for Professionals in Infection Control and Epidemiology). Staff member I stated she had not done any other education in Infection Control. Record review of the facilities personnel file for staff member I did not show documentation of education, training, certification, or experience in Infection Prevention.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure specific surveillance, tracking, and trending of infections were established for the Infection Prevention and Control Program. This deficient practice had the potential to affect all patients receiving care within the facility. Findings include: During an interview on 7/30/24 at 3:30 p.m., staff member I stated she had no documentation of surveillance, tracking or trending of infections. Staff member I stated, “I tried tracking and trending, but it just didn’t work for me.” Review of a facility document titled, “Infection Prevention and Control,” undated, showed: ... “The infection Prevention and Control Committee is a multidisciplinary committee which oversees the program for prevention, surveillance, data analysis, and control of infection.””

“LEADERSHIP RESPONSIBILITIES CFR(s): (1) The governing body, or responsible individual, must ensure all of the following: (i) Systems are in place and operational for the tracking of all infection surveillance, prevention and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure a system was in place for active surveillance, prevention, and control of all infections, to include antibiotic use. This deficient practice had the potential to affect all patients and staff within the facility. Findings include: During an interview on 7/30/24 at 3:30 p.m., staff member I stated there was not any documentation showing surveillance, tracking or trending of infections or antibiotic use. Staff member I stated, “We have a urine thing (McGreer’s Criteria) we are supposed to follow, but nobody follows it. The providers order what they want. I have gotten resistance and push back from the providers when I mention it to them.” Review of a facility document titled, “Antimicrobial Stewardship Program,” dated, 4/28/22, showed: ... “5. Track-hospital monitors antibiotic use 6. Report-Prescribers receive feedback by the stewardship program about how they can improve their antibiotic prescribing 7. Educate-the stewardship program provide education to clinicians and other relevant staff on improving antibiotic use” [sic]”

“LEADERSHIP RESPONSIBILITIES CFR(s): (ii) All HAIs and other infectious diseases identified by the infection prevention and control program as well as antibiotic use issues identified by the antibiotic stewardship program are addressed in collaboration with the CAH’s QAPI leadership. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to integrate all Healthcare Associated Infections, Antibiotic Stewardship, and other infectious diseases through the facilities QAPI leadership and program. This deficient practice had the potential to affect all patients receiving care at the facility. Findings include: During an interview on 7/30/24 at 3:30 p.m., staff member I stated, “I am not addressing anything with QA or QAPI at this time.” Review of a facility document titled, “QA/QI Minutes,” dated 6/15/23-2/22/24 and 5/15/24-7/17/24, showed no infection prevention and control attendance at the QA/QAPI meeting, or submission of information to the QA/QAPI leadership. No policy or procedure was in place for the integration of the Infection Prevention and Control Program to QAPI leadership or program.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (2) The infection prevention and control professional(s) is responsible for:] (ii) All documentation, written or electronic, of the infection prevention and control program and its surveillance, prevention, and control activities. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure complete documentation of the infection prevention and control program, to include surveillance, and tracking of infections. This deficient practice had the potential to affect all patients and staff within the facility. Findings include: During an interview on 7/30/24 at 3:30 p.m., staff member I stated she had no documentation of surveillance, tracking or trending of infections. Staff member I stated, “I tried tracking and trending, but it just did not work for me.” Review of a facility document titled, “Infection Prevention and Control,” undated, showed: ... “The infection Prevention and Control Committee is a multidisciplinary committee which oversees the program for prevention, surveillance, data analysis, and control of infection. ... 1. A written plan should serve as the foundation of any surveillance program.” ...”

“LEADERSHIP RESPONSIBILITIES CFR(s): (3) The leader(s) of the antibiotic stewardship program is responsible for:] (iv) Competency-based training and education of CAH personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the CAHs, on the practical applications of antibiotic stewardship guidelines, policies, and procedures. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure the individual employed as the Infection Prevention and Control Specialist provided competency-based training and education to all personnel and staff, including medical staff, on the practical applications of antibiotic stewardship guidelines, policies, and procedures. This deficient practice had the potential to affect all patients and staff within the facility. Findings include: During an interview on 7/30/24 at 3:30 p.m., staff member I stated she had not done any education with any of the staff. Staff member I stated, “ I have tried to educate providers on antibiotic stewardship, but providers order what they want. I have gotten resistance and push back from the providers when I mention it to them.” Review of a facility document titled, “Antimicrobial Stewardship Program,” dated, 4/28/22, showed: ... “5. Track-hospital monitors antibiotic use 6. Report-Prescribers receive feedback by the stewardship program about how they can improve their antibiotic prescribing 7. Educate-the stewardship program provide education to clinicians and other relevant staff on improving antibiotic use” [sic]”

“ORGAN, TISSUE, & EYE PROCUREMENT CFR(s): Ensure that the CAH works cooperatively with the designated OPO, tissue bank and eye bank in educating staff on donation issues, reviewing death records to improve identification of potential donors, and maintaining potential donors while necessary testing and placement of potential donated organs, tissues, and eyes takes place. §485.643(f) For purpose of these standards, the term “organ” means a human kidney, liver, heart, lung, pancreas, or intestines (or multivisceral organs). This Standard is not met as evidenced by: 35356 Based on interview and record review, the facility failed to periodically review death records with the OPO (Organ Procurement Organization) for 2 (#s 5 and 9) of 2 sampled patients who expired in the facility; failed to develop policies and procedures for the purposes identified in their agreement with the tissue and eye banks information that will allow the OPO, tissue bank and eye bank to assess the CAH’S donor potential; failed to develop and implement policy and procedures which outline the agreement with an organ and eye bank; and failed to identify areas through involvement of the facility’s OPO program with their QAPI (Quality Assurance and Performance Improvement) program to identify where the OPO, tissue bank and eye bank staff performance might be improved. Findings include: 1. Failure to Review Death Records with OPO Review of patient #5’s EMR, dated 4/3/24 to 4/18/24, showed the patient expired in the facility on 4/18/24. The EMR showed the OPO was notified of the death in the facility. Review of patient #’s EMR, dated 12/4/23 to 12/6/23, showed the patient expired in the facility on 12/6/23. The EMR showed the OPO was notified of the death in the facility During an interview on 7/30/24 at 3:00 p.m., staff member B stated she had not reviewed any death records or been in contact with the organ or eye banks to review the death records. 2. Failure to Develop Policy and Procedures for OPO Review During an interview on 7/30/24 at 3:00 p.m., staff member B stated the facility did not have any policies and procedures for their OPO program, therefore none which permit the OPO, tissue bank and eye bank access to death record information that will allow the OPO, tissue bank and eye bank to assess the CAH’S donor potential. A review of the facility’s Organ Recovery Agreement, dated, 12/2/2013, showed: “... 2.9 Work cooperatively with [Organ Bank] to determine Hospital’s donor potential, review death records to improve identification of potential donors, develop strategies for improving donation rates, and identify areas with both [Organ Bank] and Hospital staff performance might be improved.” A review of the facility’s Policy and Procedure titled, Organ Procurement, with no date, showed, “Please refer to the Organ Procurement Policy and Procedure book.” A review of the facility’s OPO Policy and Procedure Book failed to address any policy and procedures for OPO. 3. Failure to Develop OPO Policy and Procedures A review of the facility’s Policy and Procedure titled, Organ Procurement, with no date, showed, “Please refer to the Organ Procurement Policy and Procedure book.” A review of the facility’s OPO Policy and Procedure Book failed to address any policy and procedures for OPO. 4. Failure to Incorporate OPO into QAPI During an interview on 7/30/24 at 3:00 p.m., staff member B stated the facility’s OPO program was not integrated into the facility QAPI program.”