York General Health Care Services

“Hospital CAH and LTC Emergency Power CFR(s): §482.15(e) Condition for Participation: (e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section. §483.73(e), §485.625(e), §485.542(e) (e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section. §482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1) Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated. 482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2) Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code. 482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2) Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates. *[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):] The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes. (1) National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169, www.nfpa.org, 1.617.770.3000. (i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011. (ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011. (iii) TIA 12-3 to NFPA 99, issued August 9, 2012. (iv) TIA 12-4 to NFPA 99, issued March 7, 2013. (v) TIA 12-5 to NFPA 99, issued August 1, 2013. (vi) TIA 12-6 to NFPA 99, issued March 3, 2014. (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011. (viii) TIA 12-1 to NFPA 101, issued August 11, 2011. (ix) TIA 12-2 to NFPA 101, issued October 30, 2012. (x) TIA 12-3 to NFPA 101, issued October 22, 2013. (xi) TIA 12-4 to NFPA 101, issued October 22, 2013. (xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.. This Standard is not met as evidenced by: 27395 This facility is in compliance with Emergency Preparedness regulations at E41 [483.73(e)].”

“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 39, “Existing Business Occupancies” of the 2012 Edition of the National Fire Protection Association [NFPA], Chapter 101: Life Safety Code. York General Hospital - Sleep Studies was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 483.90(a)(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition”

“42 CFR 483.90(a)(b) 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 18, New Health Care Occupancies of the 2012 Edition of the National Fire Protection Association [NFPA], Chapter 101: Life Safety Code York General Hospital is Type II (000) construction, 1 story with a basement, fully fire sprinkler protected, and smoke detection in corridors and spaces open to the corridors. A Business Occupancy is separated by a 2-hour fire barrier. York General Hospital was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 483.90(a)(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition.”

“General Requirements - Other CFR(s): NFPA 101 General Requirements - Other List in the REMARKS section any LSC Section 18.1 and 19.1 General 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: 27395 Based on observation and staff interview, the facility failed to use electrical wiring in a way that would not create a fire hazard. This condition increased the potential to cause a fire. Findings are: Observation on 8/22/24, at 12:17 pm revealed: 1. A fan was plugged into a power strip in Sleep Studies 2. 2. Three fans were plugged into a power strip in the Sleep Studies Control Room. In an interview on 8/22/24, at 12:17 pm, Maintenance A acknowledged the findings. NFPA 70, 2011, 210.23 Permissible Loads. In no case shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size specified in 210.23(A) through (D) and as summarized in 210.24 and table 210.24.”

“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: 27395 Based on record review and staff interview, the facility failed to document cleaning inside and behind the dryer, and inside the dryer duct in the Laundry. This deficient practice would increase the potential for a fire from the buildup of lint in the dryer and in the ductwork venting to the outside. Findings are: Record review on 8/22/24, at 11:10 am revealed no documentation to verify routine cleaning was conducted in and around the Laundry dryer, and documentation of at least annual inspection/cleaning of the dryer duct. During an interview on 8/22/24, at 11:10 am, Maintenance A confirmed the annual inspection/cleaning was not conducted, but stated routine cleaning of the dryer was conducted, but not documented. NFPA 211, 2010, 13.2 Annual Inspection. Chimneys, fireplaces, and vents shall be inspected at least once a year in accordance with the requirements of Section 14.2. Exception: Type B and Type BW gas venting systems. 13.2.1 Cleaning, maintenance, and repairs shall be done if necessary. NFPA 101, 2012, 19.1.1.3.1 All health care facilities shall be designed, constructed, maintained, and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 18.7.1.4 through 18.7.1.7 This Standard is not met as evidenced by: 27395 Based on record review and staff interview, the facility failed to conduct fire drills quarterly for each shift under varying conditions. This practice would not provide the necessary training for staff to respond effectively in the event of a fire. Findings are: Record review on 8/22/24, at 10:40 am revealed: 1. A fire drill was not conducted for the 1st and 3rd shifts in the 1st quarter of 2024. 2. Fire drill times where not varied by 1-hour for the 2024 1st shift 4/29 at 2:45 pm, and 7/12 at 2:30 pm. 3. Fire drill times where not varied by 1-hour for the 2024 2nd shift 5/31 at 3:02 pm, and 8/21 at 3:10 pm. 4. Fire drill times where not varied by 1-hour for various shifts in 2023. In an interview on 8/22/24, at 10:40 am, Maintenance A acknowledged the findings.”

“RECORDS SYSTEM CFR(s): All orders of doctors of medicine or osteopathy or other practitioners, reports of treatments and medications, nursing notes and documentation of complications, and other pertinent information necessary to monitor the patient’s progress, such as temperature graphics, progress notes describing the patient’s response to treatment; and This Standard is not met as evidenced by: 48575 Based on policy and procedure review, medical record review, and staff interviews the facility failed to document a pain reassessment for 1 (Patient 24) of 5 sampled patients discharged from the emergency department (ED). This failed practice has the potential to cause negative outcomes for all patients who present to the ED. There were 5,292 ED visits for FY 2023. Findings are: A. Review of policy titled Transfer and Emergency Exam (Effective 4/24) revealed Registered Nurse (RN) responsibilities included: Provide nursing care and document nursing assessments and interventions in the Electronic Medical Record (EMR) system and the ED Medication Record in accordance with ED documentation procedures. B. Review of Patient 24’s medical record (8/19/2024 at 3:12PM) revealed that Patient 24 arrived at the ED on 7/24/2024 at 1:15PM with a chief complaint of abdominal pain and a past medical history of a cesarean section (surgically remove baby from abdomen) 7 weeks prior. Triage vitals at 1:19 PM included Temperature 98F, Blood pressure 118/75, heart rate 87, Oxygen saturation 97% on room air. RN-B documented a pain score of 9/10 to Patient 24’s abdomen on 7/24/2024 at 2:18PM and gave intravenous (IV) Morphine (a pain medication that goes through the vein) and IV Zofran (a medication to reduce or relieve nausea or vomiting that goes through the vein) at 2:19 PM. Patient 24’s entire medical record lacked evidence of a documented pain reassessment prior to discharge at 4:16 PM. C. Interview with RN-A (8/20/2024 at 3:37PM) confirmed that they did not re-assess Patient 24’s pain prior to discharge on 7/24/2024.”