Sidney Health Center

“EP Training Program CFR(s): §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: 40068 Based on interview and record review the facility failed to implement the initial and annual training of the EP program to all staff members, consistent with each team members’ expected roles during an emergency or a disaster. Findings include: Record review of the facility EP plan and training documents on 9/4/24 revealed, the facility did not have documentation that staff training for the EP plan was conducted initially for new staff and every other year for all current staff. During an interview on 9/4/24 at 8:30 a.m., staff member A stated he did not have documentation of staff who have completed emergency preparedness training upon hire and every two years after.”

“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 09/04/24. Under this regulatory requirement, the facility must meet the applicable provisions of the National Fire Protection Association’s (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 II (111). There is a two-hour separation between the Clinic and CAH for this facility. There is also a two-hour wall separation between the Health Works Fitness Center and the CAH. The Health Works Fitness Center (building 2) and the Engineering and Storage (building 6) are located in the basement. The CAH facility exists in the Aspen Central Office system as 6 buildings as follows: Building 01 - CAH Building 02 - Health Works Fitness Center Building 03 - Clinic Building 04 - 2009 Surgery Remodel Building 05 - Bypass Corridor & Shell Space Building 06 - Engineering & Storage These requirements were not met as evidenced by the following deficiencies:”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 40068 Based on observation and interview, the facility failed to provide emergency lighting per NFPA 101-2012, Sections 39.2.9.1, and 7.9.2.7. Findings include: During an observation and interview on 9/4/24 at 12:30 p.m. the emergency light in the ortho suite by the nurse’s station was observed. The light was making a low buzzing sound. Staff member C stated the light has been buzzing like that for a while and does not work when the power goes out. Staff member C stated, “it’s pitch black in here when there is no power.””

“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: 40068 Based on observation and interview, the facility failed to maintain exit signage illuminated in accordance with NFPA 101, 2012 Edition, Section 7.10.5.1, 7.10.5.2, and 7.10.5.2.1. Findings include: During an observation on 9/4/24 at 12:26 p.m. the ortho suite was observed. The marked exit by the nurse’s station was not internally illuminated. During an observation and interview on 9/4/24 at 12:30 p.m. the emergency light in the ortho suite by the nurse’s station was observed. The light was making a low buzzing sound. Staff member C stated the light has been buzzing like that for a while and does not work when the power goes out. Staff member C stated, “it’s pitch black in here when there is no power.””

“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: 40068 Based on an observation and interview, the facility failed to assure 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, 19.3.2.1.3 and 19.3.2.1.5 (6) (7). Findings include: 1. During an observation and interview on 9/4/24 at 10:20 a.m., the soiled work room was inspected. The room was over 50 square feet and was used to store dirty linen. The self-closure had been removed from the door. Staff member B stated the room was used to store dirty linen. 2. During an observation on 9/4/24 at 11:42 a.m., the ER equipment storage room was inspected. The room was over 50 square feet, used as storage, and would not close and latch under the power of the self-closure.”

“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: 40068 Based on observation, the facility failed to ensure an alcohol-based hand rub (ABHR) dispenser was not mounted within 1 inch of an ignition source in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8 b). Findings include: 1. During an observation on 9/4/24 at 11:30 a.m., room six in the ER was inspected. A hand sanitizer pump was installed within one inch of an ignition source. 2. During an observation on 9/4/24 at 11:40 a.m., room three in the ER was inspected. A hand sanitizer pump was installed within one inch of an ignition source.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 40068 Based on record review and interview, the facility failed to ensure that load voltage tests were conducted on the batteries of the fire alarm control panel (FACP) semi-annually, as required per NFPA 72-2010, Table 14.4.5 (6). Findings include: During a review of the most recent facility fire alarm inspection on 9/4/24, the fire alarm system was inspected on 9/26/23. There was no documentation the semi-annual voltage test had been completed by the facility. During an interview on 9/4/24 at 1:14 p.m., staff member B stated the 6-month voltage test had not been completed.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 40068 Based on an observation the facility failed to ensure a sprinkler head was installed clear of a ceiling mounted fixture in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2. Findings Include: During an observation on 9/4/24 at 12:04 p.m. the kitchen janitor closet was inspected. A sprinkler head was obstructed by a ceiling mounted light fixture.”

“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 the facility failed to: a) Maintain cover plates for concealed sprinklers in accordance with NFPA 13, 2010 Edition, Section 6.2.7.1, 6.2.7.3, b) Maintain escutcheon rings in accordance with NFPA 13, 2010 Edition, Section 6.2.7.1, and c) ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1 (3). d) ensure sprinkler head pendants are unobstructed from the ceiling in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.4.1.1.1 Findings include: 1. During an observation on 9/4/24 at 10:07 a.m., room 201 in med surge was inspected. Two concealed sprinkler heads were missing cover plates. 2. During an observation on 9/4/24 at 10:24 a.m., the nurse call closet was inspected. There were two perforations in the ceiling tiles, and the sprinkler head was missing an escutcheon ring. 3. During an observation on 9/4/24 at 10:39 a.m. the nursery work room was inspected. There was a loose escutcheon ring, causing gapping around the sprinkler head which could interrupt activation time if there were a fire. 4. During an observation on 9/4/24 at 10:41 a.m. the OB janitor closet was inspected. There was a loose escutcheon ring, causing gapping around the sprinkler head which could interrupt activation time if there were a fire. 5. During an observation on 9/4/24 at 10:43 a.m. the admin IDF closet was inspected. There were multiple cords running through the ceiling tiles resulting in unsealed penetrations in the ceiling tiles. 6. During an observation on 9/4/24 at 11:28 a.m., ultrasound room two was inspected. The sprinkler deflector and the ceiling did not have the minimum clearance of 1 inch. 7. During an observation on 9/4/24 at 11:48 a.m., the ED entrance was inspected. A ceiling tile was pushed up causing gapping in the ceiling tiles.”

“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 observation, the facility failed to install portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.8.1. Findings include: 1. During an observation on 9/4/24 at 11:07 a.m., the health information office was inspected. A portable fire extinguisher was mounted 69 inches from the handle to the floor. 2. During an observation on 9/4/24 at 12:00 p.m., the kitchen was inspected. The portable K-type fire extinguisher was mounted 69 inches from the handle to the floor.”

“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 observations, the facility failed to maintain egress doors in accordance with NFPA 101-2012, Sections 7.2.1.4.1 and 7.2.1.4.5.1. Findings include: During an observation on 9/4/24 at 11:26 a.m., the soiled work room was inspected. The egress door was prevented from fully opening by boxes stored behind the door.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 40068 Based on observation, the facility failed to ensure smoke barriers were maintained to prevent the potential for smoke to spread in accordance with NFPA 101-2012, Section 19.3.7.3. Findings include: During an observation on 9/4/24 at 10:16 a.m., the smoke barrier on med surge was inspected. A blue wire was passing though the smoke barrier that was not properly sealed.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 40068 Based on observation, the facility failed to ensure latching fire/smoke barrier doors were maintained per NFPA 101-2012, Section 19.3.7.8., 4.2.3, and 4.6.12.1. Findings include: 1. During an observation on 9/4/24 at 10:11 a.m. the med surge fire/smoke doors were exercised. The doors failed to latch under the power of the self-closer after being exercised twice. 2. During an observation on 9/4/24 at 11:02 a.m. the fire/smoke doors located by the chapel were exercised. The doors failed to latch under the power of the self-closer after being exercised twice.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 40068 Based on record review the facility failed to ensure an annual diesel fuel supply quality test was conducted at least annually per NFPA 101 2012 Edition, Section 9.1.3.1 and NFPA 110, Section 8.1.1, 8.3.1, and 8.3.8 Findings include: Review of facility documents on 9/4/24 indicated the annual diesel fuel quality test conducted on 1/3/24 failed as reported on the certificate of analysis.”

“RECORDS SYSTEM CFR(s): The records are legible, complete, accurately documented, readily accessible, and systematically organized. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure there was a process was in place to verify consent to treat forms were obtained prior to receiving care in the facility for 4 (#s 7, 9, 11, and 19) of 26 sampled patients. This deficient practice had the potential to affect all patients who received care in the hospital. Findings include: A review of patient #7’s electronic medical record showed no consent to treat was obtained during an emergency room visit on 5/4/24. A review of patient #9’s electronic medical record showed no consent to treat was obtained during an admission to labor and delivery on 10/19/22. A review of patient #11’s electronic medical record showed no consent to treat was obtained during an acute inpatient admission on 5/25/24. During an interview on 8/28/24 at 11:55 a.m., staff member AA stated patient #19 was admitted directly to the facility’s inpatient status from the cancer center and his consent to treat must not have been obtained on admission to inpatient status. During an interview on 8/28/24 at 1:33 p.m., staff member BB stated she was responsible for the medical records department. Staff member BB stated there was not a current process in place to ensure all documents in the medical record were completed or accurate. Staff member BB stated there was no current policy or procedure in place, but she was working on getting one implemented.”

“RECORDS SYSTEM CFR(s): For each patient receiving health care services, the CAH maintains a record that includes, as applicable-- (i) Identification and social data, evidence of properly executed informed consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient; This Standard is not met as evidenced by: 44769 Based on interview and record review, the facility failed to have a complete medical record for 4 (#s 7, 9, 11, and 19) of 26 sampled residents. This deficient practice had the potential to affect all patients coming into the facility for treatment. Findings include: A review of patient #7’s electronic medical record showed no consent to treat was obtained during an emergency room visit on 5/4/24. A review of patient #9’s electronic medical record showed no consent to treat was obtained during an admission to labor and delivery on 10/19/22. A review of patient #11’s electronic medical record showed no consent to treat was obtained during an acute inpatient admission on 5/25/24. A review of patient #19’s EMR in the facility’s EHR showed an informed consent form that was unsigned. During an interview on 8/28/24 at 11:55 a.m., staff member AA stated patient #19 was admitted directly to the facility’s inpatient status from the cancer center and his consent to treat must not have been obtained on admission to inpatient status. During an interview on 8/28/24 at 12:05 p.m., staff member AA stated consent to treat forms were to be completed when a patient arrives to the facility and did not know why the consent to treat forms were not completed. During an interview on 8/28/24 at 1:33 p.m., staff member BB stated there was not a current process in place to ensure all documents were completed. A review of a facility policy titled, “Condition of Admission Forms,” with a revision date of 6/2010, showed: ... “Procedure: ... 2. Patients and/or the designated Power of Attorney, guardian/parent or family member will need to sign the Conditions of Admission. a. This form gives permission for the patient to be treated, either by the attending physician or the staff.” 47752”

“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 Program (QA). This deficient practice had the potential to affect all patients with a requested organ donor and imminent death. Findings include: During an interview on 8/27/24 at 11:03 a.m., staff member B stated she was the staff member primarily responsible for the facility’s organ procurement program and the organ procurement program was not currently included into the facility’s Quality Assurance Program. A review of the facility’s Quality Assurance minutes showed no documentation for the inclusion of the Organ Procurement Organization program (OPO).”