Avera St Anthony’s Hospital

“COMP ASSESSMENT, CARE PLAN & DISCHARGE CFR(s): §485.645(d)(5) Comprehensive assessment, comprehensive care plan, and discharge planning (§483.20(b), and §483.21(b) and (c)(2) of this chapter), except that the CAH is not required to use the resident assessment instrument (RAI) specified by the State that is required under §483.20(b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in §413.343(b) of this chapter). “ §483.20(b) Comprehensive assessments- (1) Resident assessment instrument. A facility must make a comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information. (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychosocial well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnoses and health conditions. (xi) Dental and nutritional status. (xii) Skin condition. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. (2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2) (i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition. (For purposes of this section, “readmission” means a return to the facility following a temporary absence for hospitalization or for therapeutic leave.) (ii) Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition. (For purposes of this section, a “significant change” means a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status, and requires interdisciplinary review or revision of the care plan, or both.) (iii) Not less often than once every 12 months. “ §483.21(b) Comprehensive care plans. (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25, or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25, or §483.40 but are not provided due to the resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (i) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (ii) In consultation with the resident and the resident’s representative(s)- (A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident’s representative(s). An explanation must be included in a resident’s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident’s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident’s needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. (3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. (ii) Be provided by qualified persons in accordance with each resident’s written plan of care. (iii) Be culturally-competent and trauma-informed. “ §483.21(c)(2) Discharge summary. When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident’s stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident’s status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident’s representative. (iii) Reconciliation of all pre-discharge medications with the resident’s post-discharge medications (both prescribed and over-the-counter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident’s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident’s follow up care and any post-discharge medical and non-medical services. This Standard is not met as evidenced by: 44712 Based on record review and staff interview, the facility failed to complete comprehensive care plans 5 of 5 swing bed residents (Residents 32, 33, 34, 35 and 36) reviewed. This failed practice had the potential to affect all swing bed residents. The facility had 95 swing bed admissions for fiscal year 7/1/2022 - 6/30/2023. Findings include: A. Review of Resident 32’s medical record (3/14/24 at 9:16 AM) revealed a swing bed admission of 11/14/23-11/27/23 for strengthening (physical therapy and occupational therapy). Review of the entire medical record revealed a lack of evidence of a comprehensive care plan being completed. - Review of Resident 33’s medical record (3/14/24 at 9:51 AM) revealed a swing bed admission of 11/22/23-12/4/23 for urinary tract infection. Review of the entire medical record revealed a lack of evidence of a comprehensive assessment being completed. - Review of Resident 34’s medical record (3/14/24 at 10:30 AM) revealed a swing bed admission of 1/19/24-1/30/24 for strengthening (physical therapy and occupational therapy) and chronic kidney disease (disease of the kidneys leading to kidney failure). Review of the entire medical record revealed a lack of evidence that the comprehensive care plan being completed. - Review of Resident 35’s medical record (3/14/24 at 10:54 AM) revealed a swing bed admission of 9/15/23-10/10/23 for osteomyelitis (bone infection) of right heel. Review of the entire medical record revealed a lack of evidence that the comprehensive care plan being completed. -Review of Resident 36’s medical record (3/14/24 at 11:25 AM) revealed a swing bed admission of 10/26/23-11/13/23 for strengthening (physical therapy, speech therapy and occupational therapy). Review of the entire medical record revealed a lack of evidence that the comprehensive care plan being completed. B. Interview with the Social Worker (3/14/2024 at 11:30 AM) confirmed that 5 of 5 swing bed medical records lacked evidence of documentation of a comprehensive care plan.”

“42 CFR 485.623 The facility must meet the applicable provisions of the 2012 Edition of the Life Safety Code of the National Fire Protection Association. This facility is governed by Chapter 19, Existing Health Care Occupancies of the 2012 Edition of the National Fire Protection Association [NFPA], Chapter 101: Life Safety Code. Avera St. Anthony’s Hospital is a three story building of Type II (111) construction. The building is fully sprinkled with smoke detection in the corridors and spaces open to the corridors. Avera St. Anthony’s Hospital was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 485.623, Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition.”

“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: 39858 Based on observation and interview, the facility failed to provide battery powered emergency lighting in the electrical room where the controls and switches for the emergency generator are located. This deficient practice would cause confusion and delay repairs to the generator equipment in the event of a generator failure during an emergency. The facility has the capacity for 25 beds with a census of 9 on the day of survey. Findings are: Observation on 3-12-24 at 10:55 am revealed there was no emergency light fixture with back-up battery power provided in the room containing the controls and switches for the emergency generator. During an interview on 3-12-24 at 10:55 am, Maintenance Staff A confirmed the findings. NFPA 110, 2010 ed. 7.3.1 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access.”

“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: 39858 Based on observation and interview, the facility failed to maintain the proper separation, and to assure the doors to hazardous areas would close and latch within the doorframe. This deficient practice would allow fire, smoke, and gases to migrate into the exit corridors. The facility has the capacity for 25 beds with a census of 9 on the day of survey. Findings are: Observations on 03-12-24 between 10:23 am and 12:10 pm revealed the following: 1. The door to the elevator mechanical room failed to fully close and latch within the door frame. 2. Approximately seven - 2 inch holes in the west wall of the 76 boiler room. 3. A 4 foot by 4 foot section of sheetrock missing in the ceiling of the main 76 building electrical room. 4. The north door to the laboratory room failed to latch within the door frame. During interviews on 02-12-24 between 10:23 am and 12:10 pm, Maintenance Staff A confirmed the findings.”