Chi Health Plainview 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: 46123 Based on medical record review, facility policy review and staff interview the Critical Access Hospital (CAH) failed to ensure a comprehensive assessment after day 14 of their stay for 3 of 3 swing bed patients (Patients 32, 34 and 36) and a discharge summary that included a recapitulation of the patients stay for 4 of 5 swing bed patients (Patients 32, 33, 34 and 36). This failed practice had the potential to affect all swing bed patients at the CAH. The number of swing bed patients at the CAH for Fiscal Year 2024 was 62. Findings are: A. Review of Patient 32’s medical record (3/13/25 at 8:00AM) revealed a swing bed admission of 12/18/24 - 1/14/25 for pneumonia. Review of the entire medical record revealed a lack of evidence of a comprehensive assessment within 14 calendar days after admission and evidence of a discharge summary that included a recapitulation of the patients stay. - Review of Patient 33’s medical record (3/13/25 at 8:20AM) revealed a swing bed admission of 1/21/25 - 1/28/25 for cellulitis of the right lower leg. Review of the entire medical record revealed a lack of evidence of a discharge summary that included a recapitulation of the patients stay. - Review of Patient 34’s medical record (3/13/25 at 10:00AM) revealed a swing bed admission of 8/29/24 - 9/13/24 for sepsis. Review of the entire medical record revealed a lack of evidence of a comprehensive assessment within 14 calendar days after admission and evidence of a discharge summary that included a recapitulation of the patients stay. - Review of Patient 35’s medical record (3/13/25 at 10:30AM) revealed a swing bed admission of 2/26/25 - 3/13/25 for endocarditis and osteomyelitis. Review of the entire medical record revealed a lack of evidence of a discharge summary that included a recapitulation of the patients stay. - Review of Patient 36’s medical record (3/13/25 at 11:05AM) revealed a swing bed admission of 10/9/24 - 11/4/24 for an open wound of their left lower leg. Review of the entire medical record revealed a lack of evidence of a comprehensive assessment within 14 calendar days after admission and evidence of a discharge summary that included a recapitulation of the patients stay. B. Review of facility policy Scope Of Services Level Of Care Provided in Skilled Care Swing Beds, last revised 9/2024 revealed, all swing bed patients will have a discharge summary that includes the following information: Summary (recapitulation) of the patients stay. A final summary of the patient status at the time of discharge is available to authorized persons and agencies with the consent of the patient or their legal representative. A post discharge plan of care that is developed with the participation of the patient and his or her family, which wi9ll assist the patient to adjust to his or her living environment. The policy lacks information regarding a comprehensive assessment being completed within 14 days of admission to swing bed. C. Interview with Quality RN (3/13/25 at 11:55) confirmed the above medical records lacked evidence of comprehensive assessment and a discharge summary with a recapitulation of the patients stay. D. Interview with Care Manager (3/13/25 at 11:15AM) revealed that the CAH uses the providers discharge summary note as the recapitulation of the patients stay.”

“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: 39858 Based on record review and interview, the facility failed to conduct required fuel inspection of the emergency generator. This deficient practice would not ensure the emergency generator would operate upon loss of normal power. The facility had a census of 3 on the day of survey. Findings are: During record review on 3-11-25 at 9:44 am, the facility failed produce documentation to assure a yearly fuel test was conducted on the fuel for the emergency generator. During an interview on 3-11-25 at 9:44 am, Maintenance Staff A and B confirmed the lack of fuel testing.”

“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. CHI Health Plainview is a single story, Type II (222) construction, that is sprinkled with smoke detection in corridors and spaces open to corridors. The Medical Clinic is attached with a 2 hour separation. The facility had a census of 3 on the day of survey. CHI Health Plainview 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.”

“Discharge from Exits CFR(s): NFPA 101 Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7 This Standard is not met as evidenced by: 39858 Based on observation and interview, the facility allowed abrupt changes in the elevation of the walking surfaces in a path of egress that exceeded 1/2 inch. This deficient practice could slow evacuation of the facility. The facility census on the day of survey was 3. Findings are: Observations on 3-11-25 from 11:20 am to 11:32 am revealed the following. 1. The east sidewalk egress path from the front door had abrupt one-inch changes in elevation and several holes of missing concrete. 2. The southwest sidewalk egress path from the south door had abrupt one-inch changes in elevation and several holes of missing concrete. During interviews on 3-11-254 between 11:20 am and 11:32 am, Maintenance Staff A and B confirmed the findings on the sidewalk.”

“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: 39858 Based on documentation review, observation and interview, the facility failed to provide documentation of biennial sensitivity testing of the smoke detectors. This deficient practice would cause the fire alarm system to fail to activate in a timely manner. The facility had a census of 3 on the day of survey. Findings are: Record review on 3-11-25 at 10:22 am revealed the lack of documentation of biennial sensitivity testing for the smoke detectors in the facility. During an interview on 3-11-25 at 10:22 am Maintenance Staff A and B confirmed the findings.”

“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: 39858 Based on documentation review and interview, the facility failed to provide documentation of 5-year internal inspection of the fire sprinkler system piping. This deficient practice would cause the fire sprinkler system to fail to flow the required volume of water and could plug fire sprinklers during a fire. The facility had a census of 3 on the day of survey. Findings are: Record review on 3-11-25 at 10:02 am revealed the lack of documentation of 5-year internal inspection of the fire sprinkler system. The last documented test was performed in 2018. During an interview on 3-11-25 at 10:02 am, Maintenance Staff A and B confirmed the findings.”

“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: 39858 Based on record review and interview, the facility failed to conduct required fuel inspection of the emergency generator. This deficient practice would not ensure the emergency generator would operate upon loss of normal power. The facility had a census of 3 on the day of survey. Findings are: During record review on 3-11-25 at 9:44 am, the facility failed produce documentation to assure a yearly fuel test was conducted on the fuel for the emergency generator. During an interview on 3-11-25 at 9:44 am, Maintenance Staff A and B confirmed the lack of fuel testing.”