Androscoggin Valley Hospital

“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: 43002 Based on observation, interview, and record review, it was determined that the Critical Access Hospital (CAH) failed to ensure that patient care equipment was maintained in safe operating condition in 2 of 4 outpatient setting visited. Findings include: Review on 9/30/25 of the facility’s policy titled “Testing and Inspection of Patient and Non-patient Care Equipment, dated March 1, 2022, revealed, “... To provide for the systematical testing and inspection of all clinical patient care and non-patient care equipment... A. All incoming equipment, either patient care equipment or electrical equipment, is inspected and evaluated by the Plan Services Department prior to being used in the Hospital. B. After equipment is inspected and evaluated, it is added to the master inventory list and scheduled for periodic inspections. Patient care equipment inspections intervals are based on [contracted company’s name omitted] risk-based testing (6-or 12-month intervals) and 12 month intervals for all other electrical equipment...” Observation on 9/25/25 at 8:45 a.m. of the Cardiac Rehabilitation area revealed an upper body ergometer and a recumbent bike for the lower body with an upper-body ergometer) that did not have a sticker that they had been inspected and evaluated. Interview on 9/25/25 at 8:45 a.m. with Staff C (Certified Medical Assistant Practice Manager) confirmed the above findings. Review on 9/30/25 of a work order for the upper body ergometer revealed it was last inspected 2/4/21. Review on 9/30/25 of a purchase order for the recumbent bike for the upper and lower body was purchased on 6/10/22. There was no work order that any inspections had been done. Interview on 9/25/25 at 3:50 p.m. with Staff D (Director of Facilities) confirmed the above two exercise machines should be inspected annually. Staff D was unable to provide documentation that inspections had been done annually for the above equipment. 40522 Review on 9/25/25 of the manufacturer’s instruction for the mini-pasteurmatic equipment revealed “...Cleaning Tank...Weekly tank cleaning is recommended. Because some localities have water that is extremely corrosive, they may require that the tank be cleaned more often...Cleaning Procedure The tank should be cleaned at least once a week, or more often if local water conditions results in severe scale buildup...Checking Water Temperature The water temperature at the mid-tank point should be checked every two weeks to verify that the thermistor and heater are functioning properly 1 turn the unit off, then on. The printer will print the current temperature setpoint. 2 Allow the water in the tank to heat completely. The WATER TEMPERATURE display will show the current setpoint. 3 Lower a thermometer to the middle of the tank and verify that the water temperature is at the pasteurization setpoint...”. Observation on 9/23/25 at approximately 11:28 a.m. with Staff E (Clinical Supervisor for Cardiopulmonary) in the sleep medicine department on the third floor revealed a mini-pasteurmatic device ( a machine that provides High-Level Disinfection through pasteurization by submersion in hot water) located in a storage room. Interview on 9/23/25 at approximately 11:28 a.m. with Staff E confirmed the mini-pasteurmatic device was in use. Staff E revealed the mini-pasteurmatic device was used for cleaning and disinfecting the masks and tubing used for sleep study tests. Further interview with Staff E revealed that for maintenace they empty and replace the water in the mini-pasteurmatic equipment and check water temperature weekly. Staff E was unable to provide documentation of the weekly water temperature checks, chaning the water or cleaning in the mini-pasteurmatic equipment. Interview on 9/25/25 at 3:50 p.m. with Staff D revealed that he/she was unaware there was a mini-pasteurmatic device in the sleep medicine department. Staff D was unable to provide documentation of annual inspection of the mini-pasteurmatic equipment after 3/2021.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 43002 Based on observation, interview and record review, it was determined that the Critical Access Hospital (CAH) failed to employ methods for disinfecting equipment to prevent the potential transmission of infections in 2 of 4 outpatient settings visited. Findings include: Review on 9/24/25 of the Digital Ultrasonic Diagnostic Imagine System User Manual for the above ultrasound machine and probe, provided by the facility, revealed, “ ...14.2. Cleaning and Disinfection ... 14.2.2. Probe and Probe Holder Cleaning and Disinfection ... To clean the probes: Disconnect the probe from the system. Wipe off all the gel gently with a soft cloth. Rinse the probe with enough distilled water to remove all visible soap residues. Air dry or dry with a soft cloth ...To disinfect the probe: Disinfection should be performed each time after use: 1. Prepare the disinfectant (2.4% glutaraldehyde or 0.55% ortho-Phthalaldehyde). 2. Place the cleaned and dried probe in contact with the disinfectant ... for the time specified by the disinfectant manufacturer ... 3. After removing from the disinfectant, rinse the probe according to the disinfectant instructions. Flush all residues from the probe and perform air dry ... Proper Use of Probes ... Each time after use, clean and disinfect the probe ...” Observation on 9/24/25 at 11:25 a.m. of the outpatient obstetrics/gynecology department revealed an ultrasound machine with an ultrasound transducer (a transvaginal probe) attached to it. Interview on 9/24/25 at 11:25 a.m. with Staff A (Certified Medical Assistant) revealed that the probe was used for internal vaginal ultrasound during exams and that Staff A cleaned the probe after use with germicidal wipes. Interview on 9/24/25 at 2:25 p.m. with Staff A confirmed they did disinfect the transvaginal probe with 2.4% glutaraldehyde or 0.55% ortho-Phthalaldehyde according to manufacturer’s instructions. Review on 9/25/25 of the CAH’s policy for the facility Surgical Associates titled “Infection Control Policy” dated May 9, 2025, revealed, “Purpose: To establish guidelines to minimize and prevent the spread of infection ... 5. Medical instruments or equipment must be cleaned and the either disinfected or sterilized after each use according to manufacturer’s instructions ...” Review on 9/25/25 of the CAH’s policy for the Imaging Service Department titled “Infection Control Policy” dated November 1, 2022, revealed, “ ...d. Disinfection, anti-sepsis, and pertinent environmental controls ... ii. Ultrasound transducers are to be disinfected between patients using the Trophon high level disinfection unit ...”. 40522 Review on 9/25/25 of the manufacturer’s instruction for the mini-pasteurmatic equipment revealed “...Operation CAUTION Before using the Mini-Pasteurmatic, read and be familiar with the entire manual, including warnings, cautions, and notes...Intended Use The Mini-Pasteurmatic is intended for high level disinfection of respiratory and anesthesia parts; it is used in a healthcare setting by health-care workers....What Parts can be Pasteurized? Reusable respiratory therapy and anesthesia breathing circuit parts can tolerate pasteurization without harm..CAUTION All parts should be inspected after processing for normal wear and/or damage...Pasteurizing Temperature Definitions Minimum Pasteurizing Temperature: 158 [degrees] F [Fahrenheit]...for 30 minutes...Maximum Pasteurizing Temperature: 170 [degrees] F...for 30 minutes Above this temperature some plastics may be damaged...Pasteurizing Set Temperature: Nominally 166 [degrees] F [plus or minus] 2 [degrees] F The pasteurizing temperature of Mini-Pasteurmatic is preset...Start Pasteurizing Cycle With basket submerged, press START CYCLE...to begin a pasteurizing cycle. The CYCLE ON light illuminates and the CYCLE TIME REMAINING display shows “30” and the timer begins counting down the 30-minute pasteurizing cycle. In addition, the printer prints “PASTEURIZATION START” followed by the date, time, and water temperature...The printer continues to print the date, time, and water temperature at five-minute intervals throughout the pasteurization cycle. Complete Pasteurization Cycle At the end of the pasteurization cycle, an audible signal sounds, the CYCLE TIME REMAINING display goes blank, and the print out shows “Elapsed time = [equals] 30 minutes PASTEURIZATION COMPLETE.” Press Advance to expose the signature line...before tearing off the printout...”. Observation on 9/23/25 at approximately 11:28 a.m. with Staff E (Clinical Supervisor for Cardiopulmonary) in the sleep medicine department on the third floor revealed a mini-pasteurmatic device ( a machine that provides High-Level Disinfection through pasteurization by submersion in hot water) in a storage room. Interview on 9/23/25 at approximately 11:28 a.m. with Staff E revealed the mini-pasteurmatic device was used for cleaning and disinfecting the masks and tubing used for the sleep study tests. Staff E was unable to provide documentation of the results of pasteurization cycle to validate high level disinfection of the masks and tuning disinfected using the mini-pasteurmatic equipment. Review on 9/25/25 of the CAH’s policy titled, Disinfection of Masks, Tubing, and Humidifiers Using Mini-Pasteurmatic, dated 1/30/24, revealed “...The Mini-Pasteurmatic is intended for the high-level disinfection of sleep and respiratory parts...Parts (masks, tubing, and humidifiers) are loaded in the perforated baskets and submerged in the water that is maintained at the pasteurizing set temperature of 166 [degrees] F [Fahrenheit]...The cycle is complete when the CYCLE ON indicator dims, an audible sound emits, and the printer documents the cycle has been competed...”. Interview on 9/29/25 at approximately 1:15 p.m. with Staff E confirmed that they failed to document the results of the pasteurization cycle to validate high level disinfection when using the mini-pasteurmatic equipment.”

“42 CFR 485.625 K-3 BUILDING: 0101 K-6 PLAN APPROVAL: 1978 K-7 SURVEY UNDER: 2012 Existing Healthcare Occupancies K-8 Critical Access Hospital (CAH) Type of Structure: A four story (4), 1978 concrete, poured in place, type 1 (332) fire resistive building construction with full sprinkler (wet) protection in required areas. The facility was surveyed pursuant to the National Fire Protection Association (NFPA) 101 Life Safety Code, (2012 edition) as referenced in 42 CFR 485.625 Critical Access Hospital (CAH) Physical Environment on 09/24/25 and 09/25/25 with deficiencies cited. The statement of deficiencies (SOD) was sent to the provider on 11/18/25 end date of the survey to the date the SOD was issued to the provider per CMS government shutdown guidance.”

“Stairways and Smokeproof Enclosures CFR(s): NFPA 101 Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 This Standard is not met as evidenced by: 33306 NFPA 101 Life Safety Code (2012 Edition) 7.2.2.4 Guards and handrails. 7.2.2.4.1. Handrails. 7.2.2.4.1.1 Stairs and ramps shall have handrails on both sides, unless otherwise permitted in (not applicable). 7.2.2.4.1.2 In addition to the handrails required at the sides of stairs by 7.2.2.4.1.1 both of the following provisions shall apply: (1) For new stairs, handrails shall be provided within 30” of all portions of the required egress width. (2) For existing stairs, handrails shall meet the following criteria: (a) They shall be provided within 44” inches of all portions of the required egress width. (b) Such stairs shall not have their egress capacity adjusted to a higher occupant load than permitted by the capacity factor in table 7.3.3.11 if the stairs clear width between handrails exceed 60”. 7.2.2.4.2 Continuity. Required guards and handrails shall continue for the full length of each flight of stairs. At turns of new stairs, inside handrails shall be continuous between flights at landings. 7.2.2.4.3 Projections. The design of guards, handrails, and hardware for attaching handrails to guards, balusters, or walls shall be such that there are no projections that might engage loose clothing. Openings in guards shall be designed to prevent loose clothing from becoming wedged in such openings. 7.2.2.4.4.2 Existing required handrails shall not be less than 30” inches, and not more than 38” inches, above the surface of the tread, measured vertically to the top of the rail from the leading edge of the tread. 7.2.2.4.4.3 The height of required handrails that form part of a guard shall be permitted to exceed 38” inches, but shall not exceed 42” inches, measured vertically to the top of the rail from the leading edge of the tread. Based on observations and interview, it was determined the facility failed to ensure there was one set of egress stairs, exceeding 44” inches between the existing handrail width, and creating a large opening across the stairway (6-vertical steps) without an available access to a safety handrail within the center span. Findings include: Observations during tour on 09/25/25 between 10:00 a.m. and 10:15 a.m. with Staff A (Director of Plant Services) revealed the second floor stairway (6-vertical steps), between the second floor Lobby and the long stairway down to the first floor Gift Shop entrance, measures 11’- 4” (eleven feet and four inches) across and (approximately) 3’-10” (three feet and ten inches) tall, and is only equipped with (two) safety handrails on the very outside ends of the stairway. Interview on 09/25/25 between 10:00 a.m. and 10:15 a.m. with Staff A confirmed the above findings, existing safety handrail conditions, and overall stairway width of 11”- 4” between the existing safety handrails.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 33306 NFPA 101 Life Safety Code (2012 edition) 8.3 Fire barriers used to provide enclosure, subdivision, or protection under this code shall be classified in accordance with one of the following fire resistance ratings: 1. 3-hour fire resistance rating 2. 2-hour fire resistance rating 3. 1-hour fire resistance rating 4. 1/2-hour fire resistance rating 8.3.1.2 Fire barriers shall comply with one of the following: (1) The fire barriers are continuous from outside wall or from one fire barrier to another, or a combination thereof. including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. (2) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, and from the floor to the bottom of the interstitial space, provided that the construction assembly forming the bottom of the interstitial space has a fire resistance rating not less than that of the fire barrier. 8.5 Smoke Barriers 8.5.2.1 Smoke barriers required by this code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof. 8.5.2.2 Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces. 8.5.6.2 Penetrations for Cables. Cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or a through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke. Based on observations and interview, it was determined the facility failed to ensure five (5) locations with unprotected penetrations through a rated smoke/fire barrier are appropriately sealed (fire stopped) to resist the passage of smoke or the effects from smoke or fire. Findings include: Observations during tour on 09/25/25 between 12:00 p.m. and 2:30 p.m. with Staff A (Director of Plant Operations), Staff B (Executive Assistant to the President/CEO) revealed the five (5) following locations, descriptions, and existing unprotected penetrations through the rated smoke or fire barrier walls: 1. Above the suspended ceiling on the 2nd floor, in the corridor directly outside the Blood Draw area #-2151 (as labeled on the floor plan presented) in the Phlebotomy suite, has one (1) unprotected penetration from a white electrical wire passing through the 1-hour fire-rated barrier wall assembly (possibly powering an automatic handi-cap door opening control). 2. Above the suspended ceiling on the 2nd floor, directly above the entrance door to the Phlebotomy suite #-2150 (as labeled on the floor plan presented), has one (1) unprotected penetration from a Flexible Metal Conduit (FMC) passing through the 1-hour fire-rated barrier wall assembly. 3. Above the suspended ceiling on the 2nd floor, in the Audio suite #-2102 (as labeled on the floor plan presented), has two (2) blue CAT-5 wires, two (2) yellow computer wires, and one (1) white electrical wire passing through a four inch x four inch (4”x 4”) unprotected hole in the drywall that was removed from the 1-hour fire-rated barrier wall assembly. 4. Above the suspended ceiling on the 3rd floor, in the corridor directly outside the Soiled Utility room #-3072 (as labeled on the floor plan presented) has two (2) one and a half inch (1-1/2”) copper pipes with exposed open ends into the 1-hour smoke rated barrier wall assembly. 5. Above the suspended ceiling on the 3rd floor, in the corridor directly outside the Central Services Decontamination entrance door #-3546A (as labeled on the floor plan presented) has one (1) unprotected penetration from a blue CAT-5 wire and two (2) unprotected penetrations from Flexible Metal Conduits (FMC) passing through the 1-hour smoke-rated barrier wall assembly. Interview on 09/25/25 between 12:00 p.m. and 2:30 p.m. with Staff A and Staff B confirmed the above findings, locations, and existing unprotected barrier wall penetrations.”

“Electrical Systems - Wet Procedure Locations CFR(s): NFPA 101 Electrical Systems - Wet Procedure Locations Operating rooms are considered wet procedure locations, unless otherwise determined by a risk assessment conducted by the facility governing body. Operating rooms defined as wet locations are protected by either isolated power or ground-fault circuit interrupters. A written record of the risk assessment is maintained and available for inspection. 6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2 This Standard is not met as evidenced by: 33306 GFCI (Ground Fault Circuit Interrupter) outlets should be tested regularly, at least monthly, to ensure they are functioning properly and protecting against electrical hazards. The testing procedure involves pressing the “test” button on the GFCI, which should interrupt the power, and then pressing the “reset” button to restore power. If the GFCI fails to trip when the test button is pressed, it needs to be replaced. Here’s a more detailed breakdown: 1. Regular Testing: GFCI outlets should be tested at least once a month, and more frequently in areas with high usage or where water is present. Portable GFCI units should be tested before each use. Testing helps ensure the GFCI is operational and can quickly interrupt power in case of a ground fault. 2. Testing Procedure: Step 1: Reset Button: Press the reset button to restore power to the outlet. Step 2: Plug in Device: Plug in a low-wattage device, like a lamp or nightlight, to verify the outlet is working. Step 3: Press Test Button: Press the test button on the GFCI. Step 4: Check for Power Interruption: The device plugged into the outlet should turn off when the test button is pressed. Step 5: Reset Button (Again): Press the reset button again to restore power to the outlet. Step 6: Check for Power Return: The device plugged in should turn back on. Based on record review and interview, it was determined the facility failed to ensure GFCI (Ground Fault Circuit Interrupter) outlets are tested on a monthly basis. Findings include: Record review during tour on 09/24/25 between 8:00 a.m. and 11:00 a.m. with Staff A (Director of Plant Services) and Staff B (Executive Assistant to the President/CEO) revealed the facility had only been testing and documenting the GFCI (Ground Fault Circuit Interrupter) outlets on a quarterly (3-month) basis for the previous 36-months. Interview on 09/24/25 with Staff A and Staff B confirmed the above findings and available quarterly electrical testing documentation.”