Chi Oakes Hospital

“PATIENT CARE POLICIES CFR(s): §485.635(a)(2) The policies are developed with the advice of members of the CAH’s professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1). §485.635(a)(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. This Standard is not met as evidenced by: 42397 Based on policy review, committee meeting minutes review, and staff interview, the Critical Access Hospital (CAH) failed to have the required members of a group of professional personnel review the CAH’s health care policies for 1 of 1 year (2024) reviewed. Failure to have the required group of professional personnel review the policies limited the CAH’s ability to ensure the policies were current and followed regulations and standards of practice. Findings include: Review of the policy “Policies & Procedures: Development, Revision, & Deletion” occurred on 01/09/25. This policy, revised 02/2023, stated, “. . . Procedure: 1. All [facility name] policies are to be reviewed by the Policy Review Committee every two (2) years. . . 3. The Policy Review Committee will consist of at minimum . . . b. Advanced practice provider . . .” The policy failed to define the advanced practice provider as a physician assistant/nurse practitioner/clinical nurse specialist (a required member of a group of professional personnel). Review of the CAH’s policies occurred on all days of the survey. The policies lacked evidence of review in 2024 by a physician assistant/nurse practitioner/clinical nurse specialist (a required member of a group of professional personnel). Review of the Policy Review Committee meeting minutes occurred on 01/07/25. The 2024 minutes lacked evidence of attendance by a physician assistant/nurse practitioner/clinical nurse specialist (a required member of a group of professional personnel). Upon request on 01/07/25, the CAH failed to provide evidence a physician assistant/nurse practitioner/clinical nurse specialist reviewed the CAH’s policies. During interview on the afternoon of 01/07/25, an administrative staff member (#1) confirmed the CAH failed to have a physician assistant/nurse practitioner/clinical nurse specialist review the CAH’s policies.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 42397 Based on professional reference review and staff interview, the Critical Access Hospital (CAH) failed to develop an infection prevention and control program, as documented in its policies and procedures, that employed methods for preventing and controlling the transmission of infections for 3 of 3 days of survey (January 6-8, 2025). Failure to develop and implement a water management program for Legionella, develop policies and procedures to reduce the risk of growth and spread of Legionella, and conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system placed staff and patients at risk of developing Legionella infections. Findings include: Information from the Centers of Disease Control, found at https://www.cdc.gov/control-legionella, stated, “. . . The Centers for Medicare & Medicaid Services (CMS) requires healthcare facilities develop and adhere to ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) - compliant water management programs (WMPs). WMPs minimize the risk of growth and spread of Legionella [a type of bacteria that causes Legionnaires’ disease and Pontiac fever] and other pathogens in building water systems. . . .” Upon request on 01/06/25, the CAH failed to provide evidence of a risk assessment and policies/procedures for a Legionella water management program. During interview on 01/07/25 at 7:45 a.m., an environmental services supervisor (#3) confirmed the facility failed to complete a risk assessment and develop policies/procedures for a Legionella water management program.”

“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: 31889 Testing of required emergency lighting systems shall be permitted to be conducted as follows: 1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds. 2) The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. 3) Functional testing shall be conducted annually for a minimum of 1½ hours if the emergency lighting system is battery powered. 4) The emergency lighting equipment shall be fully operational for the duration of the tests. 5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 7.9.3.1.1 The facility failed to ensure the emergency lighting was in proper operating condition to provide 1½ hours of emergency illumination in the event of failure of normal lighting. Review of records indicated the facility failed to conduct monthly 30-second tests on the Operating Room emergency lights or a 90-minute annual test of all the emergency battery back-up lights in the past year. Failure to provide emergency lighting as required increases the risk of death or injury due to fire. The deficiency affected all emergency battery back-up lights in the building.”

“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: 31889 Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 19.3.4.1 A fire alarm system required for life safety shall be installed, tested and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 9.6.1.3 The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with NFPA 72, National Fire Alarm Code. Review of documentation determined: Device test results (alarm initiating, supervisory alarm initiating, and notification) did not provide an itemized list with the device type, address, location, and test result as required. Failure to install, test and maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire. The deficiency affected the complete fire alarm system, which serves the entire building.”

“Building Services - Other CFR(s): NFPA 101 Building Services - Other List in the REMARKS section any LSC Section 18.5 and 19.5 Building Services 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. This Standard is not met as evidenced by: 31889 Fire dampers shall be tested and inspected in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. All tests shall be completed in a safe manner by personnel wearing personal protective equipment. Full unobstructed access to the fire or combination fire/smoke damper shall be verified and corrected as required. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts. The damper frame shall not be penetrated by any foreign objects that would affect fire damper operations. The damper shall not be blocked from closure in any way. The fusible link shall be reinstalled after testing is complete. If the link is damaged or painted, it shall be replaced with a link of the same size, temperature, and load rating. All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. All documentation shall be maintained and made available for review by the AHJ. 19.5, NFPA 80, 19.4 The facility failed to test and inspect fire dampers as required by NFPA 80. Documentation was not available to determine testing of fire dampers throughout the facility. Failure to maintain fire dampers in accordance with NFPA 80 increases the risk of death or injury due to fire. This deficiency affected all fire dampers in the facility.”