East Ohio Regional Hospital

“Basis and Scope CFR(s): §482.1 Basis and scope. (a) Statutory basis. (1) Section 1861(e) of the [Social Security] Act provides that- (i) Hospitals participating in Medicare must meet certain specified requirements; and (ii) The Secretary may impose additional requirements if they are found necessary in the interest of the health and safety of the individuals who are furnished services in hospitals. . . . (b) Scope. Except as provided in subpart A of part 488 of this chapter, the provisions of this part serve as the basis of survey activities for the purpose of determining whether a hospital qualifies for a provider agreement under Medicare and Medicaid. This Condition is not met as evidenced by: 21893 Based on record review, observation, and staff interview, the hospital failed to be primarily engaged in providing services to function as a Hospital. The hospital ceased providing inpatient care and failed to to provide access for the community to their emergency department (ED) through the emergency transport system. This affected two patients (#5 and #6) who presented to the emergency room and required hospital admission. This had the potential to affect any patients who presented to the emergency room or received any outpatient surgical procedure. Findings include: Interview on 03/10/25 at 2:47 PM with the Director of Quality and Risk (Staff #110) revealed the hospital’s ED was still open to walk-in patients, but on full diversion of ambulances bringing patients to the ED. This occurred following payroll/staffing shortages as of 03/07/25. The hospital consolidated the intensive care unit (ICU) and medical surgical units on 03/07/25 following payroll and staffing shortages. Staff #110 verified hospital employees did not receive their scheduled pay on 03/07/25 and have still not been paid. Observations on 03/11/25 from 1:45 PM to 2:47 PM of the ED and the inpatient units revealed no patients were observed in the inpatient units. During the observations, interviews with the ED Nurse Manager (Staff #111) and Staff #110 revealed the ED was on diversion for all ambulances and had been since 03/07/25. They were only taking walk-in patients. Staff #111 stated they are not admitting patients at this time and any patient needing admission would have to be transferred to another facility. Staff #110 verified the hospital was not accepting inpatients at this time. Interview on 03/11/25 at 5:33 PM with ED Physician (Staff #200) revealed he was told by administration on 03/06/25 not to admit any ED patients to the hospital after 1:00 PM on 03/07/25. Currently there were two patients waiting for transfer to another facility. One who had been waiting in the ED for over 24 hours. Staff #200 stated both patients could have easily been admitted to the hospital had admissions been permitted. Review of the medical record for Patient #5 revealed arrival in the ED on 03/07/25 at 12:10 PM. The patient had an upper respiratory infection and needed to be admitted for pneumonia. The ED physician noted “Unfortunately we do not have a bed available” and the patient had to be transferred to another acute care facility. The patient left with transport on 03/08/25 at 8:30 AM. Review of the medical record for Patient #6 revealed arrival in the ED on 03/10/25 at 6:12 PM. The patient was found to have pneumonia and sepsis and needed admission. The ED physician noted the facility was on diversion and the patient had to be transferred to another acute care facility. The patient was held in the ED due to the inability to find a bed for the patient at other facilities. The patient left with transport on 03/12/25 at 12:24 AM. Observation on 03/21/25 at 9:35 A.M. of the hospital’s parking lot and main entrance doors revealed no cars in the parking lot and locked entry doors. Signage on the doors revealed,”Hospital Closed! Please go to the nearest hospital Trinity, Reynolds, or Wheeling!” Observations of the Emergency Department and Outpatient Surgery entrance doors revealed both doors were locked and had the same signage as the front entrance door. Continued observation revealed four cars in the physician’s parking lot. The entrance door to the outpatient physician’s offices (attached building to the main hospital) revealed the doors were unlocked. Inside, all offices were closed other than the office for Physicians Assistant, Gynecology, #500. Interview with the receptionist, Receptionist #501, revealed no patients were being seen today and the staff was facilitating the removal of office and medical supplies, answering phone calls from patients, assisting patients with medical record requests, and reviewing patient labs and test results. Observation revealed all elevators and doors leading out of the outpatient physician’s office area to the main hospital building were locked or unaccessible without a security badge or code. This observation was confirmed with Security/Maintenance #100. Security/Maintenance #100 stated when asked his title, “I’m Security, Maintenance, everything” and stated that he was in charge. He stated there was no Administration staff in the facility to his knowledge and he was there to help in any way, because he owed it to the community and patients, and he was there for them.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 21893 Based on observations, document review, record review, staff interviews, and interviews with outside vendors, the facility failed to pay staff and failed to continue to provide employee health benefits, which resulted in a sudden reduction in the available staff on duty 24/7 to allow the hospital to continue to provide inpatient services and a fully operational emergency department. Additionally, the facility failed to provide payment to vendors for supplies and services to continue to provide the necessary services for patients which included surgeries, outpatient procedures, pain management devices, transportation, laboratory tests, and blood transfusions as a functional hospital. (A0063).”

“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 21893 Based on observations, document review, record review, staff interviews, and interviews with outside vendors, the facility failed to pay staff and failed to continue to provide employee health benefits, which resulted in a sudden reduction in the available staff on duty 24/7 to allow the hospital to continue to provide inpatient services and a fully operational emergency department. Additionally, the facility failed to provide payment to vendors for supplies and services to continue to provide the necessary services for patients which included surgeries, outpatient procedures, pain management devices, transportation, laboratory tests, and blood transfusions as a functional hospital. This has the potential to affect anyone presenting to the facility for care. Findings include: 1. Interviews from 03/10/25 through 03/13/25 with two physicians (Staff #200 and Staff #492), Registered Nurses (RN) #102, Operating Room Manager (Staff #112), Licensed Practical Nurse (LPN) #364, LPN #384, Personal Care Assistant #301, Lab Director of Operations #116, Surgical Technician #440, and Pulmonary Rehab/Respiratory Therapist #484 revealed none received their scheduled paycheck on 03/07/25 and still have not been paid. Interview on 03/10/25 at 2:47 PM with the Director of Quality and Risk (Staff #110) revealed the hospital’s emergency department (ED) was still open to walk-in patients, but on full diversion for ambulances bringing patients to the ED. This occurred following payroll/staffing shortages as of last Friday, 03/07/25. The hospital consolidated the intensive care unit (ICU) and medical surgical units on 03/07/25 following payroll and staffing shortages. Staff #110 verified hospital employees did not receive their scheduled pay on 03/07/25 and have still not been paid. The hospital stated they stopped the employee health insurance coverage on 02/17/25. Observation of the ICU on 03/10/25 at 3:42 PM revealed one patient. Observations on 03/11/25 from 1:45 PM to 2:47 PM of the ED and the inpatient units revealed no patients were observed in the inpatient units. During the observations, interviews with the ED Nurse Manager (Staff #111) and Staff #110 revealed the ED was on diversion for all ambulances and had been since 03/07/25. They were only taking walk-in patients. Staff #111 stated they are not admitting patients at this time and any patient needing admission would have to be transferred to another facility. Staff #110 verified the hospital was not accepting inpatients at this time. Interview on 03/11/25 at 5:33 PM with ED Physician (Staff #200) revealed he was told by administration last Thursday, 03/06/25, not to admit any ED patients to the hospital after 1:00 PM on Friday, 03/07/25. Currently there were two patients waiting to transfer to another facility. One who had been waiting in the ED for over 24 hours. Staff #200 stated both patients could have easily been admitted to the hospital had admissions been permitted. Staff #200 stated he was employed by the hospital and did not receive his pay check last Friday. He was very worried about his malpractice insurance coverage being canceled just as his health insurance was canceled. Staff #200 stated there have been supply shortages for several weeks. For example, there was only one central line kit and he was told by the ED manager not to use it unless absolutely necessary. Staff #200 stated he had to use the last kit on a critical patient and was unsure how long it took for the central line kit to be replaced. Staff #200 stated he had to retrieve intravenous (IV) flushes from his own medical supply bag because there weren’t any in the ED about three weeks ago. Staff #200 stated the house supervisor had to go to a local drug store to buy alcohol wipes and urinals for patients due to supply shortages. The physician stated there has not been a respiratory therapist in the hospital since 7:00 AM this morning and he was concerned a patient will come to the ED who will need ventilation. Interview on 03/12/25 at 9:30 AM with Registered Nurse (RN) #491 revealed there was no respiratory therapist (RT) working on day shift yesterday or today, as one RT and the Director of Respiratory resigned. The night shift RT was on duty. RN #491 stated she had to search for IV fluids and IV flushes from other floors in the hospital. RN #491 stated two to three months ago there was an issue obtaining continuous bladder irrigation systems and IV flushes in the ED. Interview on 03/12/25 at 1:38 PM with Physician (Staff #492) revealed the vendors were not getting paid by the hospital owner and he was currently seeking alternative employment at another hospital. Observations on 03/13/25 at 3:50 PM were made in the ED due to an overhead page for Pulmonary Rehab to the ED. The ED Licensed Practical Nurse (LPN) (Staff #384) stated they needed an arterial blood gas so Pulmonary Rehab was paged overhead. Staff #200 stated the system will only allow a RT to run the blood gases on the machine. Staff #200 stated the RT from Pulmonary Rehab told him she doesn’t know how to do blood gases and does not have access to the blood gas machine. There are currently no other RTs in the facility. Staff #200 stated he will have to use other means to evaluate this patient. Staff #200 stated he personally could set up and operate a ventilator, but could not speak for anyone else. Review of the medical record for Patient #5 revealed arrival in the ED on 03/07/25 at 12:10 PM. The patient had an upper respiratory infection and needed to be admitted for pneumonia. The ED physician noted “Unfortunately we do not have a bed available” and the patient had to be transferred to another acute care facility. The patient left with transport on 03/08/25 at 8:30 AM. Review of the medical record for Patient #6 revealed arrival in the ED on 03/10/25 at 6:12 PM. The patient was found to have pneumonia and sepsis and needed admission. The ED physician noted the facility was on diversion and the patient had to be transferred to another acute care facility. The patient was held in the ED due to the inability to find a bed for the patient at other facilities. The patient left with transport on 03/12/25 at 12:24 AM. Interview on 03/14/25 at 9:40 A.M. with Staff #110 revealed Human Resources and department managers are meeting today to furlough employees. The hospital will retain only the necessary employees required to support the emergency department being open. This would include nursing, physicians, laboratory, and radiology staff. The hospital provided a list of 28 staff members who have resigned as of 03/14/25 due to not being paid. 2. Interviews on 03/10/25, 03/11/25, 03/12/25, 03/13/25, 03/14/25, and 03/17/25 between 8:00 AM through 4:00 PM with the Chief Operating Officer/Chief Nursing Officer (COO), Staff #110, and Accounts Payable/Accounts Receivable (Staff #303) revealed the hospital has outstanding balances on accounts with suppliers who provide necessary services to maintain the hospital in a full operational status. Review of the The Vendor Balance (Summary) sheet dated 03/11/25 revealed the outstanding net amount owed was $14,070,192.82. A. Review of the outstanding balance amount for Advanced Sterilization Products (ASP) was $182,680.05. This vendor provides equipment and supplies for surgical equipment, including sterilization. Review of email communication between ASP Accounts Representative and the Manager of Sterile Processing and Materials Management (Staff #122) revealed beginning on 11/19/24 ASP North America Accounts Receivable notified the hospital their account was on hold due to non-payment, overdue balances, and they were on a credit hold notice. The balance at that time was $62,022.61. ASP sent subsequent email communications dated 11/29/24, 12/04/24, 12/12/24,12/20/24, and 01/22/25 requesting updates and payments to outstanding balances. An email dated 02/21/25 revealed the hospital had an outstanding balance of $62,022.21 dating back to August 2024. The full balance was three to six months past due. While ASP had allowed orders to continue beyond the 90-day mark they now require at least partial payment before processing any additional orders. To move forward ASP can approve a small consumable order under these conditions: 1) Payment of $31,000 plus the cost of the consumable order, not exceeding $1000. 2) A written commitment to pay the remaining balance $31,022.61 within 30 days. 3) Payment must be made via Automated Clearing House (ACH) to expedite processing. Payments by check will delay the order until funds are deposited, check images will not suffice. The email contained the following “Important: we are unable to release any service contract invoices at this time. All future product and service orders will require pre-payment.” There was no response from the hospital to ASP email until 03/07/25 when the hospital asked ASP if it would be possible to pay $20,000 plus a prepay for an order that does not exceed $1000 with the agreement the hospital will pay the rest in a month. ASP’s response to the hospital, dated 03/10/25, revealed they were not willing to adjust the terms of the payment. Interview on 03/12/25 at 3:50 PM with Staff #303 verified ASP currently has the hospital on a credit hold and no payments have been made. Staff #303 verified the last payment to ASP was made on 06/24/24. Interview on 03/11/25 at 10:20 AM, and again at 4:53 PM via phone, with Staff #122 revealed two Evotech machines are used for reprocessing of the scopes. The Evotech machines do a chemical disinfection of scopes and are located in the surgery (OR) department. The two Evotech machines are not working due to the need for part replacements. The hospital is currently doing a pre-clean of the scopes after a procedure, such as a colonoscopy or Esophagogastroduodenoscopy (EGD), and sending the scopes off site to Digestive Health Center (DHC) for processing. DHC reprocesses the scopes and returns them to the hospital. The hospital currently has clean, reprocessed scopes onsite in the OR department. The low heat disinfection machine in sterile processing is out of hydrogen cartridges. Therefore, the hospital cannot disinfect laparoscopes, cameras, and other items which cannot tolerate the high heat disinfection used in the Evotech machines. The hospital’s failure to have the needed hydrogen cartridges would not prevent a laparoscopic procedure, but would prevent it from being done laparoscopic with the camera. ASP is the supplier used to supply replacement parts needed for the Evotech machines and also the supplier of the hydrogen cartridges to disinfect some equipment. ASP currently has the hospital on a credit hold due to the hospital’s failure to pay their bill. Observations were made on 03/12/25 from 8:50 AM through 9:30 AM in the OR area including two endoscopy suites, the clean room, and the decontamination room for scope cleaning. In Endoscopy Suite #2 three bronchoscopes were observed hanging in the clean storage cabinet. In the clean room, five containers marked clean were observed. Staff #112 and Staff #440 were interviewed during the observations. Staff #112 and Staff #440 stated these were scopes returned from the facility that reprocessed them. They stated the two Evotech machines, which reprocess the scopes, were not working. Scopes reprocessed in these Evotechs started failing around December 2024. At that time, the facility almost had to cancel scope procedures. An outside facility started reprocessing the scopes at that time. The technicians do the bedside cleaning of the scope after a procedure, then scrub and flush the scope in the decontamination room. Used scopes are then placed in individual containers marked dirty and sent out to the outside facility for reprocessing. The reprocessed scopes are then returned to the facility marked clean. The Evotechs have not been repaired due to the vendor not getting paid. The staff stated procedures are canceled if they do not have all the needed supplies. Staff #112 and Staff #440 stated they have not had health insurance for the last seven months and did not receive their last paycheck. Observations were made on 03/13/24 from 9:25 AM to 9:45 AM in the Sterile Processing area . During the observations, Staff #122 was interviewed. Staff #122 stated there are two Sterrad machines, one of which is no longer in service. The second Sterrad NX was not working due to needing hydrogen peroxide cassettes. The Sterrads are low heat sterilizers used to sterilize laparoscopes, cameras, and other devices that cannot handle high heat sterilization. Until the hydrogen peroxide cassettes can be purchased and received, the facility cannot sterilize any laparoscopes or cameras. The laparoscopes and cameras that were sterilized prior to the Sterrad not working can still be used. B. Review of the Vendor Balance sheet revealed Maxx Health Inc, who supplies orthopedic implants, was owed an outstanding balance of $122,855. Staff #303 verified no payment has been made. Interview on 03/12/25 at 8:55 AM with Staff #112 revealed there have been no orthopedic cases for quite a while. This is due to the outstanding balance that has not been paid to Maxx Health. The hospital has been unable to get the needed orthopedic implants and replacements. C. Review of Vendor Balance sheet revealed Medtronic USA, a medical product supplier, was owed an outstanding balance of $33,065. Hospital Staff #303 verified no payment has been made. Interview with Physician (Staff #492) on 03/12/25 at 1:38 PM revealed he was concerned about his patients with outdated pain pumps no longer manufactured that needed replaced. Staff #49 stated he cannot replace them due to the hospital having no replacement supply due to non-payment. The pain pump replacements would be coming from Medtronic USA. Physician #492 stated some people have been waiting three months for replacements and are having to drive all the way to Marietta, Ohio for replacement. Surgical trays which cost six or seven dollars are no longer stocked due to non-payment. Staff #492 stated the surgical staff have to remove needles and things from other kits to make a useable kit. D. Review of the Vendor Balance sheet revealed McKesson Medical-Surgical, who supplies the hospital with medical supplies, was owed an outstanding balance of $116,381. Interview on 03/11/25 at 10:20 AM with Staff #122 revealed the hospital worked out a deal with this vendor. They pre-pay $17,000 for the week they want to place an order for medical supplies and then they can place the order. E. Review of the Vendor Balance sheet revealed Minerva Surgical, who provides surgical supplies, was owed an outstanding balance of $67,685. Interview on 03/11/25 at 10:20 AM with Staff #122 revealed the hospital was on a credit hold with this medical supplier. They provide supplies including ablation sets. F. Interview on 03/13/25 at 9:23 AM with the Medical Claims Assistance (MCA) COO staff, who are responsible for billing services of the hospital ambulance services, revealed the hospital ambulance services was behind in their payments and they are constantly being asked for payment. MCA COO stated they had received a check in the mail from the hospital on 03/11/25. They had deposited the check, but as of 03/13/25 they were still waiting to see if the check cleared. Review of hospital emails and documents from MCA revealed a termination notice was sent to the facility with a termination date of 05/17/24 due to lack of payment dating back to a 12/27/23 invoice date with $7644.60 being owed beyond 30 days. On 10/02/24, MCA COO emailed the hospital to inform them MCA was at the point of termination again. The hospital owed MCA $11,574.50, of which $10,065.31 was beyond 30 days old. MCA informed the hospital as of 10/20/24 all labor related to their account was to be terminated if they were not brought to current status by paying the past due amount of $10,065.31. On 11/14/24 a certified letter was sent to the hospital informing them it was a notification of termination. The balance due was $15,307.73 with $10,573.57 being over 60 days old. Per contract agreement, MCA had the right to terminate when outstanding invoices become 60 days past due. The certified letter stated it was a 10 day notice, MCA we would no longer process any new claims after 11/24/24, and would be turning the hospital over to MCA’s attorney. Staff #303 later called and spoke with MCA COO and asked what it would take to avoid termination. MCA COO explained it would take the hospital paying their entire balance and not falling behind any more. Staff #303 stated the person who signs the check would be in the next day and the bill would get paid. Four weeks later a payment of $5,804.36 was received on 12/19/24, which was not the amount agreed upon. MCA paused working on the hospital accounts awaiting payment. On 12/26/24, a letter was sent to the hospital to let them know the original termination date of 11/24/24 would stand as a result of the account not being current. A payment was then sent to MCA for the amount of $8,983.37. MCA took the hospital account off hold and began billing for their account. The check was then returned for insufficient funds on 02/24/25. MCA has put the account on hold once again. The current balance owed is $12,765.29. The check MCA had received from the hospital on 03/11/25 had been returned for insufficient funds. G. Interview on 03/11/25 at 3:00 PM with the Ambulance Supervisor (Staff #493) of the Belmont County Hospital Ambulance Service revealed the service was based at the hospital and receives both paychecks and supplies from the facility. Accounts Payable/Accounts Receivable gives them cash for gasoline for the ambulances. Their gas card was turned off following the resignation of former COO #700. If the ambulance staff do not have cash for gas, they can put it on their own credit card and will get reimbursed when they turn in a receipt. Staff #493 stated the only supply lacking was vent circuits for portable vents and earlier today, 03/11/25, they transported a ST elevation myocardial infarction (STEMI) patient to another facility from the ED. Review of the medical record for Patient #3 revealed arrival in the ED on 02/21/25 at 3:40 PM. The patient had seizure-like activity while receiving a computed tomography (CT) scan. The patient was returned to the ED, was unresponsive, apneic, and was intubated. The patient needed to be transferred to a tertiary medical center offering neurology services. Due to weather issues, no air transportation was available. The facility was also unable to arrange ground transportation. The ED physician noted the facility’s ambulance “Ventilator is not functional” so the ambulance could not transport the patient to the facility where she was accepted. A tertiary facility accepted the patient and had a bed assigned on 02/21/25 at 10:48 PM. The patient left by air ambulance on 02/22/25 at 10:55 AM, once the weather cleared. Interview on 03/11/25 at 5:33 PM with ED Physician Staff #200 revealed he has given the ambulance drivers his debit card twice to buy fuel to transport patients. H. Review of the Vendor Balance sheet revealed the American Red Cross was owed an outstanding balance of $67,298.99 for blood and supplies. Interview on 03/13/25 at 4:00 P.M. with the Laboratory Director of Operations #116 and the Chemistry and Phlebotomy Supervisor #457 revealed the Blood Bank has borrowed reagents from another facility, but is unable to perform the quality control (QC) test, as the reagents expire on 03/14/25 at midnight. Supplies have not been received because the vendor has not been paid. The Red Cross supplies blood for thee hospital, but they are not sure how much more will be available due to lack of payments. They will try to borrow if they can from another facility. Interview on 03/13/25 at 4:10 PM with Blood Bank Manager #453 revealed the hospital received their last shipment of six units on 03/07/25 and have not had to reorder yet. With the inpatient units closed and ambulances on diversion, they can manage with the blood they have on hand. The Red Cell Reagent for QC expires tomorrow and they will try to get it from another facility. If they can’t get the Red Cell Reagent, they will not be able to administer blood to patients. The Food and Drug Administration (FDA) regulations require a QC to be run every 24 hours and a type and cross match on everyone who receives blood, even if universal donor blood is used. Observation on 03/14/25 revealed one Red Cell Reagent was present at the hospital with an expiration date of April 2025. The hospital had obtained this from another hospital. I. Observation on 03/21/25 at 9:35 A.M. of the hospital’s parking lot and main entrance doors revealed no cars in the parking lot and locked entry doors. Signage on the doors revealed,”Hospital Closed! Please go to the nearest hospital Trinity, Reynolds, or Wheeling!” Observations of the Emergency Department and Outpatient Surgery entrance doors revealed both doors were locked and had the same signage as the front entrance door. Continued observation revealed four cars in the physician’s parking lot. The entrance door to the outpatient physician’s offices (attached building to the main hospital) revealed the doors were unlocked. Inside, all offices were closed other than the office for Physicians Assistant, Gynecology, #500. Interview with the receptionist, Receptionist #501, revealed no patients were being seen today and the staff was facilitating the removal of office and medical supplies, answering phone calls from patients, assisting patients with medical record requests, and reviewing patient labs and test results. Observation revealed all elevators and doors leading out of the outpatient physician’s office area to the main hospital building were locked or unaccessible without a security badge or code. This observation was confirmed with Security/Maintenance #100. Security/Maintenance #100 stated when asked his title, “I’m Security, Maintenance, everything” and stated that he was in charge. He stated there was no Administration staff in the facility to his knowledge and he was there to help in any way, because he owed it to the community and patients, and he was there for them.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 49793 Based on review of hospital financial records, review of the 2025 budget, review of the county auditor’s website, staff interview, and interview with representatives from utility suppliers and supply vendors, the facility failed to provide a complete and thorough institutional plan and budget resulting in vendors not receiving payments for services and the facility not operating at optimal means. (A0073)”

“INSTITUTIONAL PLAN AND BUDGET CFR(s): 482.12(d) The institution must have an overall institutional plan that meets the following conditions: (1) The plan must include an annual operating budget that is prepared according to generally accepted accounting principles. (2) The budget must include all anticipated income and expenses. This provision does not require that the budget identify item by item the components of each anticipated income or expense. (3) The plan must provide for capital expenditures for at least a 3-year period, including the year in which the operating budget specified in paragraph (d)(2) of this section is applicable. (4) The plan must include and identify in detail the objective of, and the anticipated sources of financing for, each anticipated capital expenditure in excess of $600,000 (or a lesser amount that is established, in accordance with section 1122(g)(1) of the Act, by the State in which the hospital is located) that relates to any of the following: (i) Acquisition of land; (ii) Improvement of land, buildings, and equipment; or (iii) The replacement, modernization, and expansion of buildings and equipment. This Standard is not met as evidenced by: 49793 Based on review of hospital financial records, review of the 2025 budget, review of the county auditor’s website, staff interview, and interview with representatives from utility suppliers and supply vendors, the facility failed to provide a complete and thorough institutional plan and budget resulting in vendors not receiving payments for services and the facility not operating at optimal means. This has the potential to affect any patient receiving care from the facility. The current census was 14. Findings include: Interviews on 02/19/25, 02/24/25, and 02/25/25 between 8:00 AM through 4:00 PM with the Chief Operating Officer/Chief Nursing Officer (COO), the Director of Quality (Staff #114), and Accounts Payable/Accounts Receivable (Staff #109) revealed the hospital has deficient accounts to suppliers who provide necessary services to maintain the hospital in a fully functioning operational status. The monetary deficiencies as of 02/25/25 include amounts owed to Cardinal Health for medications in the amount of $65,878.96, Columbia Gas for $317,043.37, a refuge removal company for $16,743.95, American Electric Power (AEP) for $233,000, Beckman Labs for $349,168.20, Eastern Ohio Wastewater for $10,078.41, the City of Martins Ferry for $3,627.13, GloFiber for $15,182.73, and Healthplan Benefit Provider for $700,000. Interview on 02/19/25 at 2:00 P.M. with the COO revealed she had communicated with the Healthplan Benefit Provider representative who reported the health plan had not been terminated (as of this date) but there was potential it could be. Per the COO there were legal discussions being conducted around the coverage for the employee’s health plan. Review of the Belmont County Auditor’s website revealed the hospital owned ten properties under the name of Access Martin’s Ferry LLC. The total amount of taxes past due for these ten properties were $1,214,357.10. Review of the 01/31/25 billing statement for Beckman Coulter,which provides the hospital material needed for specific laboratory tests, revealed the hospital owed a total of $418,993.20, which included a past due amount of $417,993.20. Interview on 02/20/25 at 1:50 P.M. with the Accounts Payable (AP) staff for Beckman Coulter revealed as of the 01/31/25 statement there was an outstanding balance of $349,168.00 owed by the hospital. Per Beckman Coulter AP staff the facility is in a legal dispute with the company and she is not sure the last time a payment was made. The AP staff stated they are still providing the needed supplies when a purchase order is placed. Interview on 02/20/25 at 1:50 P.M., Staff #109 stated money is tight right now and utilities are important but paying for care of the patients is the priority. As of 02/20/25 the hospital has $47,000 in their accounts and this is not enough to pay all of the bills. Review of the billing statements from AEP revealed two separate monthly statements were sent to the hospital. The total for the two accounts due on 02/19/25 was $290,940.85, which included a past due amount of $235,707.57. The hospital showed evidence of a payment of $1000 was made to each account on 02/13/25. Interview on 02/24/25 at 9:27 A.M. with the Vendor Representative of AEP revealed the hospital was in arrears to with two open accounts. One account was in arrears for $169,000 and the second account was in arrears for $64,000. The representative stated the hospital was currently not on payment plan. The Vendor Representative stated AEP received a $1,000 payment on 02/13/25. The representative stated AEP will not issue a shut off or termination notice as AEP realizes the transparency and optics of closing a hospital for non-payment. In two or three months AEP may opt to issue or file a lawsuit against the hospital and parent ownership for non-payment, but they will not issue a shut off notice. Review of the billing statement dated 01/30/25 for Jochum Refuse revealed a total amount due of $15,460.70, which included a past due amount of $13,344.20. Interview on 02/24/25 at 10:40 A.M. with the AP staff for Jochum Refuse revealed the hospital currently has an outstanding balance in the amount of $16,743.15. The AP staff revealed the last payment received from the hospital was in July 2024 in the amount of $17,375.15, which did not cover the total amount owed. The AP staff revealed they have not provided a cut off notice as they were told they were not legally able to do so because it is a hospital. Interview on 02/24/25 at 11:00 A.M. with COO revealed the hospital has applied for an open line of credit on 12/02/24. It is in the final stages of approval and to be dispersed soon, but the COO cannot verify an exact date for receiving the monies. The COO stated there is a meeting daily with accounts receivable (AR)/AP in which they decide which vendor/bill gets attention. Review of the billing statement for Columbia Gas of Ohio, dated 01/22/25, revealed the hospital had current charges of $281,165.20 due on 02/05/25, which included a past due amount of $245,567.69. Interview on 02/24/25 at 12:27 P.M. with Columbia Gas Customer Service Representative revealed the hospital has an outstanding balance in the amount of $317,043.37 due by 03/05/25. The hospital’s last payment was made on 06/21/24. The representative from Columbia Gas stated the hospital was not on a payment plan. Review of the billing statement from Cardinal Health dated 01/31/25 revealed the hospital owed a total of $65,878.96, which included a past due amount of $26,166.32. Review of the billing statements dated 01/02/25 from the City of Martin’s Ferry Water and Utilities revealed three separate bills for services provided to the operating room, sub-basement, and west mechanical areas. The total owed for all three bills was $3627.13, which included a past due amount of $2508.89. Each of the three bills contained the statement “Previous balance due immediately to avoid being shut off!” Review of the billing statement from Eastern Ohio Regional Wastewater Authority revealed a total of $10,078.41 due on 02/20/25, which included a past due amount of $6,934.17. Review of the billing statement dated 08/01/24 from Glofiber revealed a total due of $15,182.73, which included a past due amount of $2,877.65. The bill for for telephone services. Review of the hospital’s 2025 budget revealed the annual budget did not reflect an accurate budgeted amounts for gas, other utilities, and real estate taxes. The budget also does not demonstrate repayment plans for the overdue accounts. Interview on 02/25/25 at 1:35 PM with Staff #114 revealed they do not have the utilities on repayment plans as they know the utilities will not disconnect services for non-payment.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 44810 Based on observation, interview and record review, the facility failed to provide a complete and thorough institutional plan and budget resulting in supplies not being available for patient use and patient care equipment not operating at optimal means. See A0073.”

“LICENSURE OF HOSPITAL CFR(s): 482.11(b) The hospital must be - o Licensed; or o Approved as meeting standards for licensing established by the agency of the State or locality responsible for licensing hospitals. This Standard is not met as evidenced by: 44810 Based on interview and record review the facility failed to meet licensing standards as established by the state agency. Findings include: Record review revealed the facility had not applied for hospital licensure as required by the State of Ohio. During an interview on 01/21/25 at 10:35 A.M., Administrative Assistant Staff L and Staff A confirmed that the letter they provided was only for hospital registration, not hospital licensure. Staff A reported that the former Chief Executive Officer (CEO) informed her that he had taken care of it. After a call to the old CEO, Staff A went into a former employee’s office and found the state licensure application completed and sitting on their desk. The application was dated 09/28/24 and was completed by the former CEO. Staff A reported that the former CEO had given the completed form to his old accountant and asked her to pay the fee and send the application and it never was submitted.”

“INSTITUTIONAL PLAN AND BUDGET CFR(s): 482.12(d) The institution must have an overall institutional plan that meets the following conditions: (1) The plan must include an annual operating budget that is prepared according to generally accepted accounting principles. (2) The budget must include all anticipated income and expenses. This provision does not require that the budget identify item by item the components of each anticipated income or expense. (3) The plan must provide for capital expenditures for at least a 3-year period, including the year in which the operating budget specified in paragraph (d)(2) of this section is applicable. (4) The plan must include and identify in detail the objective of, and the anticipated sources of financing for, each anticipated capital expenditure in excess of $600,000 (or a lesser amount that is established, in accordance with section 1122(g)(1) of the Act, by the State in which the hospital is located) that relates to any of the following: (i) Acquisition of land; (ii) Improvement of land, buildings, and equipment; or (iii) The replacement, modernization, and expansion of buildings and equipment. This Standard is not met as evidenced by: 44810 Based on observation, interview, and record review, the facility failed to provide a complete and thorough institutional plan and budget resulting in supplies not being available for patient use and patient care equipment not operating at optimal means. Findings include: Review of the board of advisor minutes dated 09/23/24 revealed that the board questioned vendor payments because of rumors heard in the community and a lengthy discussion ensued. No further discussions were documented in the meeting minutes dated 11/11/24. Review of the facility’s list of vendors and what was owed revealed that all vendors were called in September 2024 and payment plans were set up and balances with the vendors were listed. They revealed credits to balances greater than $200,000. Review of the facility budget for 2024 revealed the budget listed for operational costs and billing but no further details were available related to capital gains and improvements and no three years look back was listed. The budget also was not approved by the board of governors and was not approved by a third party. Tour of the intensive care unit, general medical floor, radiology department, and central supply on 12/31/24 at 2:00 P.M. revealed the intensive care unit had cups and three male urinals in the supply room. Each patient had a cup at bedside. The general medical floor had no male urinals with six bags of cups in the supply room. Staff A confirmed the supply room had no male urinals available. Tour of the radiology department revealed plenty of supplies in the radiology supply room for patient care. The CT scanner did have a make shift ventilation system set up to control the temperature around the CT scanner that was vented out through the ceiling into another room. There was a thermostat observed on the CT scanner stating 71 degrees Fahrenheit (F) and one two feet away from the scanner on the wall stating 74 degrees F). Staff F stated that the CT scanner does need a new motor to keep it cool and the part has been ordered but it was on back order. She stated they monitor the temperatures throughout the day. Tour of the central supply room revealed no male urinals available on the shelf. Interview with Staff H and I during the tour confirmed the facility did not have any male urinals available in central supply and the last time they were ordered was 12/20/24 and only nine were ordered. Review of the facility supply delivery sheets from 10/01/24 to 12/31/24 revealed the facility received deliveries weekly to every two weeks of general supplies for the units. There were no deliveries from 12/09/24 to 12/27/24. Review of the quote for the CT scanner revealed the quote was written on 12/03/24. There was no evidence the quote was paid. Review of the male urinal orders revealed one case was ordered on 12/05/24 and one case consists of 48 urinals. Another order was placed on 12/20/24 for nine individual male urinals. Both orders were marked as delivered. Review of the delivery ticket for 12/31/24 from the medical supply vendors revealed no male urinals were in the order. Review of the CT scanner order form confirmed the motor for the CT scanner was not ordered until 01/02/25. During an interview on 12/31/24 at 12:10 P.M., Director of Quality Staff A stated she was unsure what the institutional plan and budget was, and all the facility had to offer was the 2024 budget which she confirmed had no documentation that analysis was done or if it was approved by the board. She stated the Chief Nursing Officer (CNO), Chief Operation Officer (COO), and Vice President of Revenue Cycle Staff B were unsure what the institutional plan and budget was either. During an interview on 12/31/24 at 1:05 P.M., Accountant Staff C, Staff A, and Staff B stated the facility does not have an institutional plan and budget. Staff B stated she just took the position over three months ago and has since hired a new chief financial officer and a new billing company, neither of which are onsite at the hospital. They are working with the department heads to see and set budgets for their departments. She stated they are also going over the financials of the facility and looking where they need to make budget cuts and increase spending in other areas. Staff A stated when she took the facility over three months ago, Staff B and Staff C called every vendor and got current account statements and are bringing them current. During an interview on 12/31/24 at 2:45 P.M., Director of Materials Staff H stated she has, in the past month, attempted to place an order for supplies, but the order was held due to non-payment. When that happens, she notifies the Accountant Staff C, and she takes care of it. During an interview on 01/02/25 at 9:10 A.M., Staff A stated that the CT scanner repair was just a quote and did not show that the part has been ordered or paid for. During an interview on 01/02/24 at 9:53 A.M., COO Staff B and Physician Board Member Staff J stated there was a discussion on the 09/23/24 about transparency and vendor payments. They stated that a Board Member leaked private board information out to the community, and they were upset about it. They also stated the meeting held on 09/23/24 was a special meeting about that subject and due to the former CEO stepping down. After that meeting the new COO investigated all the vendors and realized the facility had no budget. Both staff members stated they were unaware they had to make an institutional plan and budget yearly. They also stated they were unaware that the plan and budget had to be approved by the board and then approved by a third party. Staff B and J stated that when they found the facility had no budget, they hired a new billing company, a Chief Financial Officer (CFO), and had set up future meetings with each department head for them to present their annual budget. During an interview on 01/02/25 at 10:30 A.M., Director of Maintenance Staff K stated the part for the CT scanner was not ordered until 01/02/25 because the facility was shopping around for other quotes which were a lot more expensive than the quote they received from the vendor on 12/03/24. Review of the facility policy titled “Board of Advisors-Consent Agenda”, effective December 2015, revealed the consent agenda should consist of routine financial, legal and administrative matters that require board action. The following items are not suitable for the consent agenda: approval of annual update of the strategic plan and approval of the annual budget.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 44810 Based on observation, staff interviews, review of the water sample testing reports, review of the facility infection control log, review of the facility policy and procedures, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to ensure the infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection (A0750).”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 44810 Based on observation, staff interviews, review of the water sample testing reports, review of the facility infection control log, review of the facility policy and procedures, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to ensure the infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection for two of 16 patients reviewed (Patient #11 and #12). This could affect all patients receiving services from the facility. The facility census was eight. Findings include: Review of facility water laboratory sample results received on 09/27/23 revealed the facility had high levels of Legionella bacteria in the water sample. The test revealed acceptable levels of less than 0.1cfu (colonized forming units)/ml (milliliters) were safe and presented little to no danger from Legionella bacteria. Test less than 0.1cfu/ml conditions may allow legionella growth and action is recommended. If 10-100cfu/ml legionella growth appears to be poorly controlled, action is recommended. Acceptable methods of remediation of portable water systems include the use of high temperatures and/or elevated chlorine levels in the system water. Re-testing to validate step after remediation of a positive result is always recommended. Review of the facility water sample results revealed 16 of the 33 areas tested were positive for Legionella. Results from the water sample test noted a level of 0.01 cfu/ml from the sink in Room 322, 12 cfu/ml from the sink in Room 320, 9.02 cfu/ml from the sink in Room 300, 0.3 cfu/ml from the sink in Room 303, 22 cfu/ml from the sink in room 305, 12 cfu/ml from the sink in room 309, 0.2 cfu/ml from the shower wand in room 311, 0.4 cfu/ml from the sink in room 316, 4.5 cfu/ml from the sink in room 318, 41 cfu/ml in the intensive care bay three, 3.2 cfu/ml in room 201, 1.2 cfu/ml in a patient and nurses’ sink in the basement, 1.5 cfu/ml in a patient and nurses’ sink in the basement, 52 cfu/ml in the emergency room bay 11 sink, 21 cfu/ml in the emergency room bay 3 sink, and 12 cfu/ml in the emergency room bay 7 sink. There was no evidence the cooling tower was checked. There was no documentation that the local or state health department was notified of the facility’s positive Legionella bacteria results. Interview on 11/22/23 at 9:50 A.M. with Staff A revealed the facility had a positive legionella test in September 2023. She reported the facility had done everything they possibly could to fix the issue, and they were waiting to be retested on 11/28/23. She reported the facility hired a new water management company in September 2023, but she was not sure why. Interview on 11/22/23 at 10:05 A.M. with Staff B reported she was unaware of any issues with the facility’s water systems. Interview on 11/22/23 at 11:35 A.M. with Staff D and Staff E revealed the facility did have another water management company in place until September 2023. They reported the old company used an ionizer system and the facility measured copper and silver levels in the water daily and that was to take care of legionella. Staff E reported he went to clean out a boiler in September 2023 and there was an enormous amount of sludge inside and the company gave him no guidance or chemicals he requested. The facility then hired a new water management company and they suggested to start fresh and to get a baseline as to where the facility stood with legionella before implementing their plan. The test was completed on 09/27/23. The water management company recommended the facility install an iclor system which will chlorinate the water. Staff E also reported that to get the proper plumbing into place for the iclor machines the facility had to hire plumbers, and they began installing those on 09/29/23. He confirmed they completed the job, and the water management company had the iclor machines installed by 10/12/23. He reported the lines were constantly flushing the systems adding chlorine to the lines. He also reported the facility had ordered all the filters for the faucets and they would be installed by 11/26/23. Both Staff D and E confirmed no test had been done of the facility’s only water-cooling tower and that all water came from the city in the same place and then branched off into four areas to service the building. Interview on 11/22/23 at 2:01 P.M. with Staff F revealed surgeries were performed as scheduled with no changes to the process. Interview on 11/28/23 at 8:29 A.M. with Staff A revealed that the water management system representative informed the facility that the filters in the faucets were unnecessary and the iclor system was handling the problem of legionella in the water and the filters would do nothing. She confirmed all filters were installed on 11/25/23 and 11/26/23. She also confirmed the facility was retesting the water today, but the results were still not available. Review of the medical record for Patient #11 revealed she had an outpatient event on 10/18/23 where she was in the facility for cardiopulmonary rehabilitation. She was then admitted to the facility on 11/03/23 and discharged on 11/07/23. She came to the emergency with complaints of shortness of breath. She was found to have pneumonia due to an unspecified organism. She was tested for influenza A and B, and COVID 19 on 11/03/23 with negative results. Review of the medical record for Patient #12 revealed he was admitted to the hospital on 09/16/23 and discharged on 09/18/23 after being treated for a fall. He was then readmitted to the hospital on 10/30/23 and discharged on 11/02/23. His chief complaint was shortness of breath and respiratory distress. Patient #12 was found to have pneumonia due to an unspecified organism. He was tested for Influenza A and B, and COVID 19 with negative results. Patient #12 was then again readmitted to the hospital on 11/09/23 and transferred to a higher level of care hospital on 11/10/23. He was admitted with shortness of breath and found to have large bilateral pleural effusions. He was tested again for influenza A and B, and COVID 19 with negative results. Review of undated facility legionella monitoring logs revealed the only dates on each sheet were one through thirty and one through thirty-one. It stated the number of patients in the facility and if their diagnosis had worsened. No other information was listed. Interview on 11/28/23 at 9:30 A.M. with Staff C revealed the facility did notify her of the positive legionella in the facility. She reported the water management company and Facilities Director were coming up with solutions to fix the problem. Staff C reported she changed none of the nursing processes during this time, but she monitored patients for signs and symptoms. Staff C also reported none of the positive areas were shut from water until the iclor machines and filters were installed because no patient was drinking water from those areas. She reported that just turning on the faucets and letting the water run would not transmit legionella. Staff C also reported that she did not have any written criteria for how she came up with how to monitor patients. She reported that she just looked at the CDC website and used information from there. She reported she was only checking active patients who were admitted and reported she did not look at readmissions or patients who had used the facility for outpatient treatments. Staff C confirmed Patient #11 and #12 were not tested for Legionnaires’ disease even though their pneumonia was caused from an unknown organism, and they had multiple trips to the hospital. Review of the CDC’s Legionnaires’ Disease publication (dated 06/06/17) revealed the following: -Legionnaires’ disease is a serious, and often deadly, lung infection (pneumonia). People usually get it by breathing in water droplets containing Legionella germs. People can also get it if contaminated water accidentally goes into the lungs while drinking. Many people being treated in health care facilities including long-term care facilities and hospitals, have conditions that put them at greater risk of getting sick and dying from Legionaries’ disease. Legionella grows best in buildings with large water systems that are not managed effectively. -76% of people got Legionnaires’ disease from a health care facility in 76% of locations reporting exposures. One in four dies from getting Legionnaires’ disease from a health care facility. -Health Care Facilities may put people at risk for Legionnaires’ disease when they do not have an effective water management program. These limit germ growth by keeping hot water temperature high enough, making sure disinfectants amounts are right, keeping water flowing (preventing stagnation), operating, and maintaining equipment to prevent slime (biofilm), organic debris, and corrosion. Monitoring factors external to buildings, such as construction, water main breaks, and changes in municipal water quality. -Contaminated water droplets can be spread by showerhead and sink faucets, jetted therapy baths, cooling units, ice machines, cooling towers, and water features. -Some people are at higher risk including adults 50 years and older, current, or former smokers, and people with weakened immune systems or chronic disease. -Health Care providers can test for Legionnaires’ disease in people with health care-associated pneumonia, especially those with severe pneumonia or in facilities where other Legionnaires’ disease cases have been identified or Legionella has been found in the water source. Health Care Facilities should report Legionella to the local public health authorities quickly and work with them to investigate and prevent additional infection. Review of the facility policy titled, Legionella Surveillance, effective and approved November 2023, revealed an updated policy to reflect the changes made remove Legionella from the system. It also stated heightened surveillance and environmental sampling, including increased suspicion for Legionella cases and increased frequency of testing above the facility’s usual testing protocols. This deficiency represents non-compliance investigated under Substantial Allegation OH00148468.”