Callaway District Hospital

“QAPI CFR(s): Condition of Participation: Quality Assessment and Performance Improvement Program The CAH must develop, implement, and maintain an effective, ongoing, CAH-wide, data-driven quality assessment and performance improvement (QAPI) program. The CAH must maintain and demonstrate evidence of the effectiveness of its QAPI program. (a) Definitions. For the purposes of this section- Adverse event means an untoward, undesirable, and usually unanticipated event that causes death or serious injury or the risk thereof. Error means the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems; and Medical error means an error that occurs in the delivery of healthcare services. This Condition is not met as evidenced by: 04546 This resulted in the Condition of Participation for Periodic Evaluation and Quality Assurance not being met. C-1225 C-1309 Based on record review, staff interview and observations, the facility failed to meet the required Condition of Participation for completion of a Quality Assurance review to include: conducting a data driven Periodic Evaluation of its total program on an annual basis as required to determine if quality of care services were delivered and/or any changes needed. The facility last annual program evaluation was completed for Fiscal year ending 7/31/2020. The facility further failed to ensure Infection Control tracking and monitoring for three (3) 3 of Three (3) endoscopes with an identifying number in the log or electronic medical record (EMR) per patient use to track potential infectious outbreaks per the Centers of Disease Control (CDC) recommendations for 6 out of 6 surgical medical records (Patients 26, 27, 28, 29, 30, 31) reviewed. This failed practice had the potential to affect all patients presenting to the CAH. There were 38 patients who received an upper and/or lower endoscope procedure from 8/23/2023 - 2/24/2024 (6 months). FY 2023 inpatient visits were 165. Findings include: A. The facility provided the last completed Annual Program Evaluation for Fiscal Year ending 7/31/2020. B. Interview with Chief Executive Officer (CEO) (2/27/2024 at 9:45 AM) stated “had received information at a conference in 2020, that the annual evaluation was no longer required and had not completed an annual program evaluation since.” C. Review of Essential Elements of a Reprocessing Program for Flexible Endoscopes-Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) (last reviewed 12/27/2018) revealed the CDC recommendations included that “each endoscope has a unique identifier to facilitate tracking. Tracking should include the ability to determine when specific endoscopes were used for specific patients, loaned to other units or facilities, reprocessed, or repaired. Tracking is also essential for responding to device or product recalls.” D. Review of Patient 26’s medical record (2/27/2024 at 7:25AM) revealed that the patient presented to the CAH on 10/3/2023 at 8:44 AM for a planned Colonoscopy (a scope with a camera is inserted into the rectum to view the bowel for irregularities and prevention of potential problems that would require interventions from a healthcare provider.) Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure. Review of Patient 27’s EMR (2/27/2024 at 8:22AM) revealed that the patient presented to the CAH on 12/4/2023 at 6:46 AM for a planned Esophagogastroduodenoscopy (EGD)(a scope with a camera is inserted into the mouth, down the throat into the esophagus to examine the upper gastrointestinal (GI) tract for irregularities and prevention of potential problems that would require interventions from a healthcare provider). Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure. Review of Patient 28’s EMR (2/27/2024 at 1:42PM) revealed that the patient presented to the CAH on 10/31/2023 at 8:45 AM for a planned Colonoscopy. Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure. Review of Patient 29’s EMR (2/27/2024 at 4:35PM) revealed that the patient presented to the CAH on 9/19/2023 at 9:09 AM for a planned Colonoscopy. Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure. Review of Patient 30’s EMR (2/28/2024 at 8:10AM) revealed that the patient presented to the CAH on 12/19/2023 at 9:00 AM for a planned EGD and Colonoscopy. The facility was not able to complete the planned colonoscopy due the bowel not cleared out prior to procedure. Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure. Review of Patient 31’s EMR (2/28/2024 at 4:58PM) revealed that the patient presented to the CAH on 2/20/2024 at 7:41 AM for a planned Colonoscopy. Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure. E. During an observation of endoscope reprocessing in the surgical area (2/27/2024 at 1:31PM) revealed the CAH has 1 upper endoscope and 2 lower endoscopes that lacked evidence of unique identifiers per scope. F. Review of the “Disinfection Soak Station Log” from dates 10/18/2022 - 2/20/2024 lacked evidence of the endoscope unique identifiers for the entire reprocessing log. G. An interview with RN-B (2/27/2024 at 1:31PM) confirmed the endoscopy processing log and EMR lacked evidence of unique identifier to track endoscopes (1 upper and 2 lower) per patient use. RN-B stated that the facility purchased a new lower endoscope (date unknown) and was unaware of the tracking requirements per CDC recommendations. 48575 The standard citation C1225 resulted in this condition to also not be met.”

“DRUG AND BIOLOGICALS CFR(s): Drugs and biologicals commonly used in life-saving procedures, including analgesics, local anesthetics, antibiotics, anticonvulsants, antidotes and emetics, serums and toxoids, antiarrythmics, cardiac glycosides, antihypertensives, diuretics, and electrolytes and replacement solutions. This Standard is not met as evidenced by: 48575 Based on review of Malignant Hypothermia Association of the United States guideance, observations, and staff interview, the Critical Access Hospital (CAH) failed to maintain readily available malignant hypothermia (MH) reversal medication to treat emergent cases in accordance with acceptable standards of practice. The facility also failed to provide a MH policy and procedure, annual MH drills and training to all staff. This failed practice had the potential to affect all patients who present to the CAH. The facility inpatient visits for FY 2023 were 165, ED visits for FY 2023 were 870. Findings include: A. According to Malignant Hypothermia Association of the United States (MHAUS) (last reviewed 2018), “Facilities that stock and have the potential to administer any triggering agent, including succinylcholine without volatile agents, should have dantrolene immediately available .... to administer dantrolene within 10 minutes of the first sign of Malignant Hypothermia (MH), in the event that a patient in that facility develops MH.” B. During observation and tour of surgical services (2/27/2024 at 1:31PM) revealed that the MH cart was located in the surgical area of the facility. The bottom drawer of the MH cart revealed outdated Dantrolene 6 vials per box, 6 boxes total: -Dantrolene 20mg/vial: (box 1) expired 9/2022 -Dantrolene 20mg/vial: (box2) expired 9/2022 -Dantrolene 20mg/vial: (box 3) expired 9/2022 -Dantrolene 20mg/vial: (box4) expired 9/2022 -Dantrolene 20mg/vial: (box 5) expired 9/2022 -Dantrolene 20mg/vial: (box6) expired 9/2022 C. During observation of the Emergency Department (ED) (2/28/2024 at 9:33AM) revealed the facility failed to have a MH cart in the ED with the required amount of medication (Dantrolene 36 vials or Ryanodex 3 vials: medication to reverse emergent high body temperature in the patient) in the event succinylcholine (medication used before emergent intubation-a tube that goes through the mouth into the airway to provide rescue breaths to the patient) would be used in an emergency. E. An interview with the Director of Nursing (DON) (2/29/2024 at 8:59AM) revealed the MH cart was no longer used or managed at the facility and misunderstood the need for the MH cart due to Succinylcholine stocked in the CAH. The DON confirmed the CAH lacked evidence of a MH policy or procedure, annual MH drills or training conducted in fiscal year 2023.”

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 44712 Based on observation, interview and record review, the Critical Access Hospital (CAH) failed to provide ongoing preventive maintenance/safety inspections for 6 of 30 patient care equipment. This failed practice had the potential to affect all patients of the CAH. The CAH had 165 inpatient admissions, 25 swing bed admissions, 870 emergency room visits and 888 outpatient specialty clinic visits for the Fiscal year 2023. Findings include: A. Tour of the outpatient specialty clinic (2/27/2024 at 9:46 AM) revealed 4 exam tables, a Mindray vital signs monitor and a dremel (used to carefully remove excess skin and overgrown nails that commonly cause infections and inflammation) that did not have a blue numerical sticker to identify any responsibility for safety/tracking of the equipment. B. Interview with Maintenance Supervisor and Director of Nursing (2/27/2024 at 1:15 PM) revealed that the facility “Puts new equipment on the floor in service for use, before it is tagged and staff leave a list of new equipment for the technician to tag and do safety checks.” C. Review of Bio-Electronics most recent service report of facility equipment service dates and next test due dates (2/28/2024 at 3:00 PM) revealed that the 6 patient care equipment were not listed on the CAH equipment file list.”

“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: 44712 Based on medical record review and staff interview, the Critical Access Hospital (CAH) failed to ensure the Important Message from Medicare was received and signed before discharge for 11 out of 20 inpatients (Patients 1, 3, 4, 5, 6, 7, 8, 9, 12, 14, 16) reviewed, and 4 out of 5 swing bed patients (Patients 33, 34, 35, 36) reviewed. The CAH also failed to ensure one 1 out of 20 inpatients and 2 of 5 swing bed patients included a properly executed informed consent. This failed practice had the potential to affect all patients admitted to the CAH. The number of inpatient admissions was 165 and Swing Bed was 25 for fiscal year 2023. Findings include: A. Review of Patient 1’s medical record (2/27/2024 at 8:16 AM) revealed an inpatient admission of 1/20/2024-1/22/2024 for Hypertensive Urgency (severely high blood pressure with no evidence of end organ damage) and Atrial Fibrillation with Rapid Ventricular Response (RVR) (quivering or rapid, irregular heartbeat). Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge. -Review of Patient 3’s medical record (2/27/2024 at 8:57 AM) revealed an inpatient admission of 10/6/2024-10/9/2024 for a ground level fall, laceration of head and Anemia (low number of red blood cells) due to blood loss. Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge. -Review of Patient 4’s medical record (2/27/2024 at 9:27 AM) revealed an inpatient admission of 9/12/2023-9/13/2023 for Atrial Fibrillation with Rapid Ventricular Response (RVR) (quivering or rapid, irregular heartbeat). Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge. -Review of Patient 5’s medical record (2/27/2024 at 10:06 AM) revealed an inpatient admission of 8/7/2023-8/10/2023 for Confusion and Disorientation. Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge and a properly executed informed consent to treat was signed. -Review of Patient 6’s medical record (2/27/2024 at 10:23 AM) revealed an inpatient admission of 8/25/2023-8/26/2023 for Complicated Urinary Tract Infection. Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge. -Review of Patient 7’s medical record (2/27/2024 at 10:38 AM) revealed an inpatient admission of 8/12/2023-8/14/2023 for Elevated Troponin Level (Protein unique to the heart muscle). Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge. -Review of Patient 8’s medical record (2/27/2024 at 10:54 AM) revealed an acute inpatient admission of 9/25/2023-9/26/2023 for Chest Pain. Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge. -Review of Patient 9’s medical record (2/27/2024 at 11:16 AM) revealed an inpatient admission of 10/10/2023-10/13/2023 for Sepsis (body’s extreme reaction to an infection) and Acute Bacterial Simple Cystitis (infection of the bladder). Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge. -Review of Patient 12’s medical record (2/27/2024 at 2:19 PM) revealed an inpatient admission of 11/14/2023-11/20/2023 for Sepsis (body’s extreme reaction to an infection) and Cystitis (infection of the bladder). Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge. -Review of Patient 33’s medical record (2/27/2024 at 3:20 PM) revealed a swing bed admission of 9/6/2023-10/10/2023 for Weakness. Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge and a properly executed informed consent to treat was signed. -Review of Patient 34’s medical record (2/28/2024 at 2:45 PM) revealed a Swing Bed admission of 1/25/2024-2/8/2024 for Low Back Pain, Compression Fracture of L2 and Post Concussion Syndrome. Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge. -Review of Patient 35’s medical record (2/28/2024 at 3:41 PM) revealed a Swing Bed admission of 8/28/2023-9/12/2023 for Status Post Spinal Surgery. Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge. -Review of Patient 36’s medical record (2/28/2024 at 4:02 PM) revealed a Swing Bed admission of 11/28/2023-9/12/2023 for Status Post Spinal Surgery. Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge and a properly executed informed consent to treat was signed. B. Interview with RN-A (2/28/2024 at 4:00 PM) confirmed that inpatients (Patients 1, 3, 4, 5, 6, 7, 8, 9, 12) and swing bed patients (Patients 33, 34, 35, 36) medical records lacked evidence of an Important Message from Medicare notice received and signed before being discharged. RN-A also confirmed that inpatient (Patient 5) and swing bed patients (Patients 33 and 36) lacked evidence of documentation that a properly executed informed consent was signed. 48575 C. Review of Patient 14’s medical record (2/28/2024 at 1:54PM) revealed an inpatient admission from 2/11/2024 - 2/16/2024 for Colitis (swelling/inflammation of the large intestine/colon-bowel), Chronic Obstructive Pulmonary Disease (COPD) without exacerbation (lung disease), and hypothyroidism (thyroid disease-low levels of the hormone, the body needs supplement to replace). Review of the entire medical record lacked evidence of the Important Message from Medicare notice was received and signed prior to discharge. Review of Patient 16’s medical record (2/28/2024 at 3:01PM) revealed an inpatient admission from 2/26/2024 - 2/28/2024 for acute on chronic respiratory failure with hypoxia (lungs not functioning without interventions that generally require treatments to improve oxygen/gas exchange). Review of the entire medical record lacked evidence of the Important Message from Medicare notice was received and signed prior to discharge. D. An interview with Registered Nurse (RN)-B (2/28/2024 at 3:15PM) confirmed Patient 14 and 16 medical records lacked evidence of the IMM was received or signed prior to discharge.”

“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: 48575 Based on medical record review, observations, review of the endoscope reprocessing log and staff interview, the Critical Access Hospital (CAH) failed to track 3 out of 3 endoscopes with an identifying number in the log or electronic medical record (EMR) per patient use to track potential infectious outbreaks per the Centers of Disease Control (CDC) recommendations for 6 out of 6 surgical medical records (Patients 26, 27, 28, 29, 30, 31) reviewed. This failed practice had the potential to affect all patients presenting to the CAH. There were 38 patients who received an upper and/or lower endoscope procedure from 8/23/2023 - 2/24/2024. Fiscal Year 2023 inpatient visits were 165. This standard resulted in the condition level citation C1300 to also not be met. Findings Include: A. Review of Essential Elements of a Reprocessing Program for Flexible Endoscopes-Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) (last reviewed 12/27/2018) revealed the CDC recommendations included that “each endoscope has a unique identifier to facilitate tracking. Tracking should include the ability to determine when specific endoscopes were used for specific patients, loaned to other units or facilities, reprocessed, or repaired. Tracking is also essential for responding to device or product recalls.” B. Review of Patient 26’s medical record (2/27/2024 at 7:25AM) revealed that the patient presented to the CAH on 10/3/2023 at 8:44 AM for a planned Colonoscopy (a scope with a camera is inserted into the rectum to view the bowel for irregularities and prevention of potential problems that would require interventions from a healthcare provider.) Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure. Review of Patient 27’s EMR (2/27/2024 at 8:22AM) revealed that the patient presented to the CAH on 12/4/2023 at 6:46 AM for a planned Esophagogastroduodenoscopy (EGD)(a scope with a camera is inserted into the mouth, down the throat into the esophagus to examine the upper gastrointestinal (GI) tract for irregularities and prevention of potential problems that would require interventions from a healthcare provider). Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure. Review of Patient 28’s EMR (2/27/2024 at 1:42PM) revealed that the patient presented to the CAH on 10/31/2023 at 8:45 AM for a planned Colonoscopy. Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure. Review of Patient 29’s EMR (2/27/2024 at 4:35PM) revealed that the patient presented to the CAH on 9/19/2023 at 9:09 AM for a planned Colonoscopy. Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure. Review of Patient 30’s EMR (2/28/2024 at 8:10AM) revealed that the patient presented to the CAH on 12/19/2023 at 9:00 AM for a planned EGD and Colonoscopy. The facility was not able to complete the planned colonoscopy due the bowel not cleared out prior to procedure. Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure. Review of Patient 31’s EMR (2/28/2024 at 4:58PM) revealed that the patient presented to the CAH on 2/20/2024 at 7:41 AM for a planned Colonoscopy. Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure. C. During an observation of endoscope reprocessing in the surgical area (2/27/2024 at 1:31PM) revealed the CAH has 1 upper endoscope and 2 lower endoscopes that lacked evidence of unique identifiers per scope. D. Review of the “Disinfection Soak Station Log” from dates 10/18/2022 - 2/20/2024 lacked evidence of the endoscope unique identifiers for the entire reprocessing log. E. An interview with RN-B (2/27/2024 at 1:31PM) confirmed the endoscopy processing log and EMR lacked evidence of unique identifier to track endoscopes (1 upper and 2 lower) per patient use. RN-B stated that the facility purchased a new lower endoscope (date unknown) and was unaware of the tracking requirements per CDC recommendations.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (4) Use objective measures to evaluate its organizational processes, functions and services. This Standard is not met as evidenced by: 04546 Based on review of the last Annual Program Evaluation (Fiscal Year ending 7/31/2020), and staff interview the CAH (Critical Access Hospital) failed to conduct a periodic evaluation of its total program on an annual basis as required to determine if quality of care services were delivered and/or any changes needed. The CAH in fiscal year ending 7/21/23 provided care for 165 inpatients. Findings include: A. The facility provided the last completed Annual Program Evaluation for Fiscal Year ending 7/31/2020. B. Interview with Chief Executive Officer (CEO) (2/27/2024 at 9:45 AM) stated “had received information at a conference in 2020, that the annual evaluation was no longer required and had not completed an annual program evaluation since.””

“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 medical record review, review of policy and procedure and staff interview, the CAH (Critical Access Hospital) failed to complete comprehensive assessments for 4 of 4 swing bed residents (Patients 32, 33, 34 and 35) and lacked comprehensive care plans on 1 of 4 swing bed residents (Patient 33) reviewed. This failed practice had the potential to affect all swing bed residents. The facility had 25 swing bed admissions for fiscal year 2023. Findings include: A. Review of Resident 32’s medical record (2/27/24 at 2:45 PM) revealed a swing bed admission of 1/26/24-2/15/24 for Osteomyelitis (bone infection) of foot, status post amputation (removal of body part) of toe. 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 (2/27/24 at 3:20 PM) revealed a swing bed admission of 9/6/23-10/10/23 for weakness. Review of the entire medical record revealed a lack of evidence of a comprehensive assessment being completed. - Review of Resident 34’s medical record (2/28/24 at 2:45 PM) revealed a swing bed admission of 1/25/24-2/8/24 for low back pain, compression fracture of L2 and post concussion syndrome. 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 (2/28/24 at 3:41 PM) revealed a swing bed admission of 8/28/23-9/12/23 for status post spinal surgery and spinal abscess (infection) post incision and drainage with revision. Review of the entire medical record revealed a lack of evidence that the comprehensive care plan being completed. B. Review of policy, “Skilled Nursing-Comprehensive Assessment” (no review date on copy received) stated a comprehensive assessment used to identify patient’s problems and needs will be completed no later than 14 days after the date of admission. C. Review of policy, “Discharge Planning Process” (no review date on copy received) stated the discharge planning team meets once/week, problems are identified by members of the team and a discharge summary care plan is completed withing 7 days. D. Interview with the RN-D (2/27/2024 at 3:15 PM) confirmed that 4 of 4 swing bed medical records lacked evidence of documentation of a comprehensive assessment and 1 of 4 lacked evidence of documentation of a comprehensive care plan.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 04546 Based on record review and staff interview, the facility failed to provide any evidence of testing and training for the facility staff as required for Emergency Preparedness procedures for the previous 4 years including calendar years of 2020, 2021, 2022 and 2023. This failed practice had the potential to affect all patients and staff of the facility. The facility listed 87 employees and provided care in the previous fiscal year ending 7/21/23 for 165 inpatients. Findings include: A. Review of the facility documents originally provided (2/27/2024 at 10:45 AM) for staff drills and education on emergency training, included documentation of one live event from 4/2/2023 involving a motorcycle versus multiple vehicle accident resulting in two patients treated in the emergency room and transferred out for further care. 14 staff signed an attendance record of the live event as being involved in delivery of patient care. No formal after action report was written including analysis of the live event therefore, any areas needing to be reviewed or changed for future similar events were lacking the completion of the requirement for facility preparedness analysis of live event to count toward the two events per year for testing requirement. The facility lacked evidence of any full scale community events training, documentation of additional real live events, any table top exercises or mock disaster drills during the 4 year time period. B. Interview (2/28/2024 at 2:11 PM) with the Chief Executive Officer (CEO) in charge of emergency preparedness revealed a lack of evidence of any annual emergency preparedness drills, training, or testing were completed at the time of the survey for the previous 4 years including calendar years of 2020, 2021, 2022 and 2023. Additionaly, no written plan for upcoming testing to include facility staff was available at the time of survey.”

“42 CFR 482.41 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. Callaway District Hospital is a one-story building that was built in 1974 with an addition added in 2000. The original building is a Type II (111) construction, and the addition is a Type III (211) construction for which the entire facility is fully sprinkled with a wet system. There is supervised smoke detection located in the corridors and spaces open to the corridors along with heat detection in the hazardous areas. The facility has 12 certified beds. At the time of the survey, the census was 4. Callaway District Hospital was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 483.90(a), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 04548 Based on record review and interview, the facility failed to conduct testing of non-hospital grade receptacles at patient bed locations, including the continuity of the grounding circuit, polarity, and retention force. This deficient practice increased the risk of fire from an outlet. The facility has the capacity for 12 beds with a census of 4 on the day of survey. Findings are: 1) Record review on 2-27-24, at 3:15 P.M. revealed: documentation of annual patient bed location receptacle testing was not provided for review. 2) During an interview on 2-27-24 at 3:15 P.M., Maintenance Staff confirmed the testing documentation was not provided and testing was not implemented. NFPA Standard: NFPA 99, 2012, 6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. 6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).”