Deer Lodge Medical Center

“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 (LSC) recertification survey was performed on 1/24/24. Under this regulatory requirement, the facility must meet the applicable provisions of the National Fire Protection Association’s (NFPA) 101 LSC, 2012 Edition, and those mandatory Codes referenced by that edition. The facility was surveyed specifically using Chapter 19 Existing Health Care Occupancies, as well as Chapter 39 Business Occupancies. Facilities surveyed under the CAH for the Centers for Medicare and Medicaid Services (CMS) Certification Number (CCN) are as follows: 1A Main Hospital 1B Clinic and Ancillary Services Building 1A is construction Type ll (111) and contains one smoke compartment. There has been an addition to the clinic area since the last survey. The facility had 1 patient at the time of survey and has 16 licensed beds. The CAH is connected to a clinic and administration area (Building 1B) with a 2 hour separation. A horizontal exit exists between these different occupancies and some services are utilized in this non sleeping compartment occupancy. These requirements were not met as evidenced by the following deficiencies:”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to ensure doors in the path of egress did not require the use of a key, a tool, or special knowledge or effort for operation from the egress side in accordance with NFPA 101-2012, Section 7.2.1.5.3, 7.2.1.5.10, and 7.2.1.6. Facilities can only lock doors and gates in the case of clinical need such as a special care unit. Findings include: 1. During an observation on 1/24/24 at 10:25 a.m., the doors leaving the recovery area were found to be maglocked, with an electronic opening push-button device marked with the universal “handicapped” symbol on the button. Entry to the recovery area was with an electronic device using a card to unlock the doors and enter. The system is set up as an “access-controlled” egress special locking arrangement. The motion detector was not a part of the system. Whatever type of special locking arrangement they want to utilize throughout the facility, either delayed egress, or access-controlled egress, the facility must then apply all the features the code requires in NFPA 101-2012 Section 7.2.1.6. The locked doors in the lighted path of egress must also unlock and be open to occupants in the event the sprinkler or fire detection systems are activated. 2. During an observation on 1/24/24 at 10:50 a.m., the back corridor to surgery had marked exit signs leading to magnetically locked doors. This was set up as an “access-controlled” egress special locking arrangement. The motion detector was not a part of the system.”

“Discharge from Exits CFR(s): NFPA 101 Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7 This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to assure that all exit discharges were provided with a hard surface path to the public way. Per NFPA 101, 2012 Edition, Sections 39.2.1.1, 7.1.6.2, and 7.7.1. The findings include: 1. The marked exit discharge from the dietary patio exit was examined on 1/24/24 at 9:45 a.m. The discharge ended on the patio with only a narrow gravel pathway to the the public way. 2. During an observation on 1/24/24 at 9:58 a.m., the north exit sidewalk out of the clinic was inspected. It was found to have ice and snow on the sidewalk going to the public way.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to maintain continuous illumination for all exit signs in accordance with NFPA 101, 2012 Edition, Section 7.10.5.1, failed to ensure all exit passageways were marked in accordance with NFPA 101 2012 Edition, Section 7.10.1.2.2., and failed to ensure a photo-luminescent sign was installed in accordance with NFPA 101 2012 Edition, Section 7.10.7.2. Findings include: 1. During an observation on 1/24/24 at 10:02 a.m., the clinic hall coming from the north exit was inspected. There was an exit sign in the corridor which was found to not be illuminated. It was discovered there was a paper sign inside the light which was blocking the illumination. 2. During an observation on 1/24/24 at 10:10 a.m., the exit signage in the hospital was inspected. There was no visible exit signage guiding occupants to the exits when standing near the nurses station. There was an exit sign hidden by the architecture of the area guiding occupants toward the main entrance, but it was not visible from most of the area. 3. During an observation on 1/24/24 at 10:10 a.m., there was a photo-luminescent exit sign at the end of the corridor near room 12. There was no continuous illumination of the face of the sign by a reliable light source to ensure “charging” of the sign in case of a power outage or an emergency.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to ensure hazardous rooms/areas had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3. Findings include: 1. During an observation on 1/24/24 at 10:12 a.m., resident room 12 was inspected. The room was being used for storage for extra beds, 4 in total. There was no self-closing device on the door.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 32381 Based record review, the facility failed to maintain the wet chemical extinguishing system for the kitchen hood in accordance with NFPA 17A, 2009 Edition, Section 7.5.1. Findings include: 1. Review of the maintenance records on 1/24/24 showed the last hydro test on the main cylinder for the kitchen hood was completed in 2011 and was due in 2023.”

“Alcohol Based Hand Rub Dispenser (ABHR) CFR(s): NFPA 101 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8). Findings include: 1. During an observation on 1/24/24 at 10:12 a.m., resident room 12 was inspected. There was an ABHR station mounted over the light switch in the room.”

“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: 32381 Based on record review and observation, the facility failed to maintain the sprinkler system in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 14.2, failed to maintain the monthly gauge readings on all of the sprinkler risers per NFPA 25-2011, Sections 5.2.4.1 and 5.2.4.2, and failed to continuously maintain the sprinkler systems per NFPA 13-2010, Section 6.7.4. Findings include: 1. During a review of facility records on 1/24/24, it was found that the 5 year internal pipe inspection for the sprinkler system had not been completed on time. The last time the internal inspection had been completed was 2017. 2. During a review of facility sprinkler maintenance records it was found the facility was not documenting monthly gauge pressure readings on the wet sprinkler side, and weekly dry side pressure readings. 3. During an observation on 1/24/24 at 10:39 a.m., the drain, and test connections and valves were not identified and permanently marked with waterproof metal or rigid plastic signs at the wet and dry risers.”

“HVAC - Direct-Vent Gas Fireplaces CFR(s): NFPA 101 Direct-Vent Gas Fireplaces Direct-vent gas fireplaces, as defined in NFPA 54, inside of all smoke compartments containing patient sleeping areas comply with the requirements of 18.5.2.3(2), 19.5.2.3(2). 18.5.2.3(2), 19.5.2.3(2), NFPA 54 This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to ensure the installation of a direct vent fireplace met all regulatory criteria in accordance with NFPA 101 2012 Edition, Section 39.5.1, 39.5.2, 9.1, 9.2.2, and 9.8. Findings include: 1. During an observation on 1/24/24 at 10:07 a.m., the main entrance lobby was inspected. There was a direct vent gas fireplace installed in the room. There was no electronically supervised carbon monoxide detector installed in the room.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 32381 Based on record review, the facility failed to ensure the fire safety plan and subsequent drills documented all requirements listed in the the code for responding to a fire drill per NFPA 101. 2012 Edition, section 19.7.1.2. Findings include: 1. Review of the facility fire drills going back a year reflected the facility lacked documentation in regards to all the elements required by code for the fire safety plan, specifically, the facility was not training staff to make a simulated emergency call to the fire department or 911. Even the system dialer will alert the monitoring agency, the code requires staff to still call 911 and report about the alarm.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 32381 Based on record review, the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 7.2.1.15.1, 4.6.12 and in accordance with NFPA 80-2010, Section 5.2 (written report). Findings include: 1. Review of the fire safety maintenance records on 1/24/24., reflected the lack of the annual fire door assembly testing documentation. The facility must identify the required fire/smoke barriers, as well as electronically controlled doors and doors with special locking arrangement in the building and show inspections of all components of the doors in those barriers.”

“Engineer Smoke Control Systems CFR(s): NFPA 101 Engineer Smoke Control Systems 2012 EXISTING When installed, engineered smoke control systems are tested in accordance with established engineering principles. Test documentation is maintained on the premises. 19.7.7 This Standard is not met as evidenced by: 32381 Based on interview, and record review the facility failed to inspect, test and document the testing and inspection of fusible link dampers in accordance with NFPA 80, Standard for Fire Door and Other Opening Protectives, 2010 Edition, Section 19.4.1.1. Findings include: During a review of facility records on 1/24/24, the fusible link dampers in the facility had not been exercised in the last six years, as there was no documentation to show they had. In an interview on 1/24/24 at 8:00 a.m., staff member B stated they had not been exercised.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 32381 Based on observation the facility failed to maintain gas cylinders per NFPA 99-2012, Section 11.6.2.3. Findings Include: 1. During an observation on 1/24/24 at 9:48 a.m., the administration area was inspected. There was a K-sized tank of helium free-standing on the floor within an office.”

“ORGAN, TISSUE, & EYE PROCUREMENT CFR(s): §485.643(a) Incorporate an agreement with an OPO designated under part 486 of this chapter, under which it must notify, in a timely manner, the OPO or a third party designated by the OPO of individuals whose death is imminent or who have died in the CAH. The OPO determines medical suitability for organ donation and, in the absence of alternative arrangements by the CAH, the OPO determines medical suitability for tissue and eye donation, using the definition of potential tissue and eye donor and the notification protocol developed in consultation with the tissue and eye banks identified by the CAH for this purpose; This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure their organ, tissue, and eye donation program (OPO) was integrated into their facility’s Quality Assurance and Performance Improvement Program (QAPI). This deficient practice had the potential to affect all patients with a requested organ donor and imminent death. Findings include: During an interview and record review on 1/17/24 at 1:20 p.m., staff member G stated the facility’s OPO program was not currently included into their QAPI, and they did not have a “score card” for it. A review of the facility’s QAPI minutes showed no documentation for the inclusion of the OPO program.”

“FREEDOM FROM ABUSE, NEGLECT & EXPLOITATION CFR(s): Freedom from abuse, neglect and exploitation (§483.12(a)(1), (a)(2), (a)(3)(i), (a)(3)(ii), (a)(4), (b)(1), (b)(2), (c)(1), (c)(2), (c)(3), and (c)(4) of this chapter). “ §483.12(a)(1) Freedom from abuse, neglect, and exploitation. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms.(a) The facility must-(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; “ §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. “ §483.12(a)(3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. “ §483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. “ §483.12(b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, “ §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This Standard is not met as evidenced by: 35356 Based on interview and record review, the facility failed to follow their established policies and procedures to provide on-going training to a contracted employee on the prohibition and prevention of patient abuse. This deficient practice had the potential to affect all facility contracted staff and those patients whom they provided care. Findings include: Review of the facility’s policy and procedure titled, Annual Refresher Training, last reviewed on 4/28/23, showed: - “Policy: It is the policy of [Facility] to have annual refresher training be an essential part of our plan to provide a safe workplace at [Facility]. Job specific safety training and facility wide safety training will be provided to employees through various platforms...” Review of the facility’s employee personnel files for staff member C did not show evidence of annual or additional sessions on abuse training. During an interview on 1/18/24 at 9:40 a.m., staff member GG stated staff member C was a contracted employee and they did not have an annual refresher training for abuse prohibition on file for staff member C.”