Peacehealth Cottage Grove Community Medical Center

“LICENSURE OF CAH CFR(s): The CAH is licensed in accordance with applicable Federal, State and local laws and regulations. This Standard is not met as evidenced by: 29708 Based on observations, interviews, review of CAH scope of services documentation, review of SA licensing documents and records, and review of other documentation it was determined that the CAH failed to ensure it was in compliance with applicable State laws and rules related to hospital licensing and changes in the building and physical environment. Hospital licensing OAR 333-500-0045 requires that a hospital submit building plans and specifications to the SA, the State of Oregon hospital licensing authority, for review and approval prior to building construction, alterations or additions. Impacted areas may not operate until building plans review and licensing processes have been completed and approval for the project(s) is received from the SA FPS Unit. The CAH failed to comply as follows: * The CAH converted an outpatient Procedure Room in the outpatient Family Medicine Clinic into outpatient Imaging Services without FPS Unit plans review and approval. Findings include: 1.a. A scope of services document that depicted the CAH’s inpatient and outpatient imaging department services titled “Department Scope of Service PeaceHealth Cottage Grove Community Medical Center Imaging Department” dated last approved 08/26/2023 reflected: * “Purpose ... an outline of the Imaging services provided within the Diagnostic Imaging Department at PeaceHealth Cottage Grove Community Medical Center in reference to what modalities are covered and during what times. This will be used as a reference for caregivers and providers.” * “The Imaging Department provides ... Cardiac Echo Ultrasound (ECHO) ...” * “Scheduled and Inpatient Cardiac/Echo ... Wednesday 0730-1600” * “Cardiac Echo: Echocardiograms are offered on Wednesday ... Cardiac Echo is performed 1 day per week on scheduled patients.” 1.b. A “Provider Letter Scope of Service” document dated 04/05/2024 reflected “Dear Clinicians and Teams, With the ebbs and flows of healthcare, along with the regrouping post pandemic, there has been some confusion as to what services Cottage Grove Imaging is currently able to provide ... Below is a list of our services:” The list included “Cardiac Echo ... Echocardiograms are offered every Wednesday ...” 1.c. Observations of a room in the CAH’s OP Family Medicine Clinic, Suite 220 with the DCO on 07/09/2024 beginning at 1325 revealed: * The entry door was numbered Door #2154. A sign in the hallway outside the entry door reflected “Wound Care and Ultrasound”. * Observations inside the room revealed a single room that contained Echocardiogram equipment and supplies and wound care equipment and supplies. 1.d. During an interview on 07/09/2024 at ~ 1340 the DCO provided the following information regarding OP Family Medicine Clinic room with entry Door #2154: * The room is “dedicated” to OP “Echo” services and OP Wound and Ostomy services. Echo Services are provided in the room on Wednesdays and Wound and Ostomy Services are provided in the room on Mondays, Tuesdays, Thursdays, and Fridays. * Echo services and Wound and Ostomy services have both been provided in the room for about one year. * Before Echo services and Wound and Ostomy services were provided in the room, it was an “outpatient clinic procedure room”. 1.e. During an interview on 07/09/2024 at ~ 1345 with a WOCN regarding Family Medicine Clinic room with entry Door #2154 they stated Wound and Ostomy services provided in that room included care and management of dehisced surgical wounds, pressure ulcers, wound vacs, ileostomies, colostomies, diabetic foot ulcers and stasis ulcers. 1.f. An email from DCO dated 07/11/2024 at 1000 reflected: * The response to “How long has OP ECHO been provided in Room (Door #2154) in the Family Medicine Clinic?” was “Approximately 10 year [sic] in clinic ... Echo has been performed in Suite 220 (FMC) since they started performing Echo at CG ... The equipment used to be stored in Imaging and then taken over to Suite 220 on Wednesdays ... Equipment stays in the room now but is covered up when not in use.” * The response to “What was that room (Door #2154) used for before OP ECHO services commenced in that room?” was “Outpatient Procedure room.” * There was no response to “Where was OP ECHO provided prior to the current room in Family Medicine Clinic?” * The response to “How long has OP Wound/Ostomy been provided in Room (Door #2154) in the Family Medicine Clinic?” was “2023”. * The response to “What was the room (Door #2154) used for before OP Wound/Ostomy services commenced in that room?” was “Outpatient procedure room”. * The response to “Where was OP Wound/Ostomy provided prior to the current room in Family Medicine Clinic?” was “In room 1090, an outpatient procedure room which alternated with Foot care.” * The response to “Describe patients who receive Wound/Ostomy services in that room (Door #2154) ...” was “Outpatients only from Family Medicine Clinic, Outpatient Geriatric Clinic, Outpatient Internal Medicine Clinic patients”. * The response to “Provide a scope of services, policy or other document that describes those OP Wound/Ostomy services and days/hours of operation” was “Outpatients only needing wound care, dressing changes, and wound debridement. Hours of Operation: Monday, Tuesday, Thursday, Friday 0900-1630”. 2. In an email from the RAC dated 07/10/2024 at 1244, the response to a request for a CAH policy that ensured the hospital submitted plans to OHA/FPS for change of use and construction/renovation projects was “We would not have a policy on this we follow OHA rules and regs.” 3. During interview on 08/16/2024 at 1105 the SA FPS Unit Manager reviewed SA licensing records and confirmed that the hospital had not submitted plans for approval of the change of outpatient Family Medicine Clinic, Suite 220 room with entry door #2154 from an OP clinic procedure room to OP Imaging Echo Services.”

“CONSTRUCTION CFR(s): The CAH is constructed, arranged, and maintained to ensure access to and safety of patients, and provides adequate space for the provision of services. This Standard is not met as evidenced by: 29708 Based on observations, interviews, review of CAH scope of services documentation, review of SA licensing documents and records, and review of other documentation it was determined that the CAH failed to ensure that the physical environment was constructed, arranged, and maintained for patient safety and to provide adequate space for the provision of services: * Building alterations had been made for OP Imaging services without the required approval of the SA. Findings include: 1. Refer to Findings 1-3 under Tag C-816 that reflects building alterations had been made without the required approval of the SA.”

“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: 44104 Based on observations, interview and review of documentation the hospital failed to fully develop and implement its preventive maintenance program. Findings include: 1.a. During a review of the Preventive Maintenance Program with the EOCM, the FS, the RAC and the contracted Trimedix SMCE, SSMCE on 07/10/2024 beginning at 1300 the following items were identified as being out of compliance with the hospital’s PMP: * A pocket doppler observed in the Family Medical Clinic had a sticker the reflected a next inspection due date of “by end of: 2-19”. * A Passport Invacare nebulizer observed in the Family Medical Clinic had a sticker the reflected a difficult to read next inspection due date of “by end of: 2-19” or “2-14”. * A Synergy nebulizer observed in the Family Medical Clinic had a sticker the reflected a next inspection due date of “by end of: 1-19”. * A Pacific Pulmonary Services nebulizer observed in the Family Medical Clinic had a sticker the reflected a next inspection due date of “by end of: 1-19”. * A refrigerator with patient food items observed in the ED hallway had a sticker the reflected a next inspection due date of “by end of: 2-23”. During the review, the contracted SMCE stated that the items were not listed in their tracking inventory. 1.b. A document provided by the RAC on 07/16/2024 confirmed Finding 1.a. The RAC stated the pocket doppler, the Synergy nebulizer, and the Pacific Pulmonary Services nebulizer would be “Added to program, install date 7/12/24. No PM required.” The RAC stated the Passport Invacare nebulizer “was not located. Staff indicated it went out with a patient. Staff will call Biomed once the device returns and they will add to the Biomed program with install date.” Regarding the refrigerator for patient food, the RAC stated “Out of scope for Biomed/Clinical Engineering”.”

“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: 44104 Based on observations, interview, documentation and review of infection control policies, and other documentation, it was determined that the CAH failed to ensure that infection prevention policies and procedures had been fully developed, implemented and monitored for compliance with protocols for the prevention and control of infection transmission within the CAH. Findings included: 1. Refer to Tag 1208 Findings 6, 7, 8, and 9. * Patient care equipment had not been maintained per manufacturer IFUs. * Cleaning, disinfection and sterilization protocols were not fully implemented per hospital policy. * Terminal cleaning of patient rooms was not fully implemented per hospital policy. Chemical and disinfectant secondary containers lacked adequate labeling for easy identification of contents and viability. Storage of patient care supplies lacked a clear separation of clean and dirty supplies. * Patient food items lacked expiration or pull dates per hospital policy. 2. Refer to Tag 1231, Finding 1, facility-wide observations reflecting that the infection prevention and control professional(s) responsible for the CAH failed to fully develop and implement facility-wide infection surveillance, prevention, and control policies and procedures that adhered to nationally recognized guidelines.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 29708 44104 Based on observations, interview, review of infection control P&Ps, and other documentation, it was determined that the CAH failed to ensure it had developed and implemented infection prevention P&Ps that demonstrated adherence to nationally recognized infection prevention and control guidelines, and to ensure it maintained a clean and sanitary environment in the following areas: * Cleaning products, hand hygiene products, and patient care supplies and equipment were expired, unlabeled, and were not maintained in accordance with nationally recognized standards or manufacturer’s instructions. * Protocols and practices for instrument/device pre-cleaning, disinfection and sterilization processes were not fully developed, implemented, and were not in accordance with nationally recognized standards. Potentially contaminated patient care items were available for use in patient care areas where sterile equipment was required. * Storage areas for patient care supplies were unorganized, lacked a clear separation between clean and dirty supplies, and were not maintained in a manner that prevented cross-contamination. * The facility’s environmental cleaning practices did not align with hospital cleaning protocols and areas under sinks had not been maintained in accordance with nationally recognized standards. * Food handling and storage was not in accordance with clear or complete protocols to ensure the prevention of food-borne illness. Findings include: 1.a. A document titled “Hydrocollator Heating Units User Manual” dated 2009 was reviewed and reflected: * “This manual contains general instruction for operation, precautionary instructions, and maintenance recommendations for the owners and operators of the Hydrocollator ... Heating Units.” * “Maintenance ... Regularly clean and drain the tank (every two weeks).” * “Remove all deposits from interior surfaces and parts. The deposits are concentrations of minerals that will allow rusting to begin. If allowed to accumulate on the heating element, these deposits will lower the efficiency of the element and increase power consumption of the unit.” * “If you suspect that you have ‘hard water’, you may need to change the water and clean the unit more frequently. Salt deposits are an indication of hard water that will eventually cause rust.” * “Cleaning Tips ... The interior of the unit should be cleaned, at lease [sic] every two weeks ...” 1.b. A Rehabilitation Services policy titled “Equipment Cleaning Policy” dated “Last Approved 2/14/2023” was reviewed and reflected: * “Owner ... Dir Rehab Services”. * “Therapeutic Equipment (including Mats and Exercise Equipment) ... All therapeutic equipment, including mats and exercise equipment, will be cleaned according to the disinfectant’s manufacturer’s recommendations at least once daily and after each patient use. Ultrasound heads may be cleaned with 70% isopropyl alcohol. Janitorial contracts will include expectations regarding cleaning frequency and product use, and will be reviewed by Infection Control.” * “This policy and procedure applies to Rehabilitation Services at the PeaceHealth locations checked below ... Cottage Grove Medical Center ...” * “Hydrocollator ... Water will be drained and tanks cleaned once a month.” * “If there is any build up of corrosives, a hospital approved cleaning product will be used to remove corrosives.” * “Unit Razors (after every use) ... Tap the cap on a hard surface to remove debris from inside the blade area ... Use the nylon brush to remove debris from the top of the razor and from under the cap of the blades ... Pull off the cap of the razor, then push down and turn the white knob underneath. This allows you to take the cap apart. Use a brush, soap, and hot water to clean all parts of the cap of the razor thoroughly. Do not put any electrical parts under water ... Wipe the cap parts with the PDI Bleach Sani-Cloth and let air dry ... Wipe down the outside of the razor, the part under the cap, and the case with a PDI Bleach Sani-Cloth [sic] Be sure all parts are allowed to air dry before reassembling and replacing the cap ... Routine maintenance will be performed a minimum of once yearly on all razors.” * There were no references cited or listed. * “Approval Signatures ... Dir Policy Admin” The document was not fully developed and implemented, and it was unclear whether the policy was based on nationally recognized standards. For example, under “Therapeutic Equipment”, it was not clear whether only “Janitorial contracts included expectations regarding cleaning frequency and product use and were reviewed by Infection Control” or whether other “cleaning frequency and product use” referenced in this policy were also reviewed by Infection Control. Additionally, it was unclear whether the manufacturer had validated the alternative cleaning schedule for the hydrocollator as the “once a month” cleaning schedule did not align with the manufacturer’s instructions for use. Refer to Finding 1.a., manufacturer recommendation to clean “every two weeks”. Further, the policy lacked professional references, such as CDC Guidelines for Sterilization and Disinfection; or whether other professional sources, such as AORN and SHEA, were considered in development of disinfection processes for shared patient equipment. For example, it was unclear whether the risks of shared razors, which have the potential to break intact skin during ordinary use, were considered and whether the hospital’s disinfection process adhered to nationally recognized standards for shared patient equipment that may encounter non-intact skin via micro cuts and abrasions, i.e., a semi critical classification. Key stakeholders, such as Infection Prevention and the Infection Control Committee, were not listed to ensure that the procedures had been evaluated for any unique infection control risks specific to the hospital’s environment or unique population, or whether the policy had been evaluated by an interdisciplinary team of personnel involved in the use and disinfection of patient razors. It was unclear whether the approver, “Dir Policy Admin” or the owner, “Dir Rehab Services” had specialized knowledge and training in preventing transmission of BBPs, waterborne pathogens, or other HAIs as the credentials of the approver or the owner were not noted. 2. A document titled “Ambulatory Education Job Aid Instrument Decontamination Process” with “Last Revision Date: 06/29/2023” was reviewed and reflected: * “All instruments used in the clinic setting must be decontaminated and transported appropriately.” * “Wipe gross debris off instruments at point of use (no soaking or scrubbing) with a 4x4 gauze.” 3.a. A document titled “Isolation Room: Discharge Cleaning” without a version date was reviewed and reflected: * A diagram with steps 1-20 reflected that step “9” was “Patient bed, bed rails, bed control, buttons and mattress (let mattress dry)”; and step “10” was “Remove and clean headboard and footboard”. 3.b. A training checklist titled “EVS ... Discharge room Cleaning” without a version date was reviewed and reflected: * The checklist contained 4 columns with the titles, “# ... Major Steps ... What’s Critical - Key Points ... [and] Why it’s Critical.” * Tasks were listed in order of completion sequence from 1 - 20. * Although “Strip sheets and blanket from the bed” were listed as task 2, cleaning the bed was not listed until tasks 11, 12 and 13. 4.a. A document titled “EVS Departmental Task - Chemical expiration” with a “Rev.” date of 05/28/2023 and “Updated - 7/16/2024”, 5 days after the survey Exit Conference, was reviewed and reflected: * “The purpose of this procedure is to provide a standard for identifying expiration dates on any chemicals used for the purpose of disinfecting in the hospital, and clinics.” * “Chemicals that are placed in a secondary container (diluted) should have the date dispensed written on the label.” * “Diluted chemicals are effective for 1 year after dilution according to manufacture recommendation.” * “All secondary containers will be labeled providing SDS information of identity of hazardous chemical, health and safety warning, manufacture, instruction for use, and contact information.” * “Chemicals included in dating: Hand sanitizer, soap, disinfectants, alcohol”. 4.b. A document titled “3M Easy Scrub Express Flat Mops System” dated “2022” was reviewed and reflected: * “Squeeze-bottle allows you to dispense the amount of cleaning solution needed for the job. Small, reusable bottles are quick to swap when your task calls for a different solution.” * “Dispensing Bottles ... 11.5 oz bottle. Compatible with nearly any cleaning solution.” 5. An undated document titled “Cottage Grove Food Supplies” was reviewed and reflected: * “Procedural Guidelines ... All items (perishable and non perishable) delivered to the floor kitchens are labeled and have an ‘expiration’ date or a scheduled ‘pull’ date, after which the item is to be removed and discarded. Expiration/pull dates are based on manufacturer/supplier recommenda- tion [sic] and Sodexo ... standards, and will be adjusted and updated as necessary.” * “Food & Nutrition Services Responsibilities ... Expired, out-of-date, opened or uncovered, unlabeled and improperly stored items will be discarded ... All nonperishable food items will be labeled with an expiration/pull date or have a ‘rotation’ timeline ... All outdated, expired, unlabeled or improperly labeled and stored food items not for patient use will be discarded.” ***** 6.a. During a tour of Rehabilitation Services on 07/10/2024 beginning at 1420 with RAC and the RSM the following was observed: * A hydrocollator with visible areas of rust on the hot pack racks, as well as white deposits on the upper portion of the racks. * Instructions for cleaning were posted above the hydrocollator that reflected it had a monthly cleaning schedule. The hospital failed to follow the manufacturer’s IFUs for regular cleaning of the hydrocollator. Refer to Findings 1.a. and 1.b., the manufacturer’s recommendation to clean the hydrocollator every two weeks and to remove all formed deposits, and the hospital policy that reflected a monthly cleaning schedule. It was unclear whether the manufacturer had validated the alternative cleaning schedule. It was unclear whether the presence of rust and and white deposits had been considered in the development of the unit’s cleaning schedule as recommended by the manufacturer, “If you suspect that you have ‘hard water’, you may need to change the water and clean the unit more frequently. Salt deposits are an indication of hard water that will eventually cause rust.” 6.b Finding 6.a. was confirmed by the RAC and the RSM at the time of the observation. 7.a. During tour of outpatient Wound Care Clinic on 07/09/2024 beginning at 1325 with DCS present, observations included: * At the handwashing sink, a wall mounted hand hygiene dispenser with lotion foam cleanser with expiration “May 2023”. * A spray bottle of Virex 256 One-Step Disinfectant Cleaner and Deodorant with no expiration date or other information that identified when the disinfectant/cleaner expired. * An open container of Ecovue Ultrasound gel with “Date Opened:” preprinted on a sticker followed by handwritten entry “7/20/23”. The manufacturer expiration date on the container was smudged and illegible. It was not clear when the Ultrasound gel expired. 7.b. The observations related to Wound Care Clinic were confirmed with DCS on 07/09/2024 at the time of the observations. 7.c. During a separate tour of the outpatient Wound Care Clinic on 07/09/2024 with the CGIP, the ASIP, and the IPONM beginning at 1400, the following was observed: * A WCRN who had provided patient care failed to wipe down instruments at point of use and instead placed instruments directly into the biohazard transport bin and sprayed the instruments with enzymatic spray. Upon further inspection, blood and tissue were observed on the instruments. * Two packets containing sterilized instruments, a pair of forceps and a pair of scissors, were noted to be in the closed and locked positions in the sterile packets. It was unclear whether all surface areas of the instruments had been successfully exposed to the sterilization process. 7.d. At the time of the observation, the WCRN was provided education by the IP staff present regarding the removal of gross debris and wiping instruments at point of use. During the IP education, the WCRN stated that they did not know they had to wipe gross debris off the used patient care instruments at point of use and did not know about the hospital’s protocol to do so. The WCRN expressed no knowledge as to the rationale for this step in the sterilization and disinfection process. Additionally, the WCRN was asked whether the sterilized instruments identified to be in the closed and locked positions were acceptable for use in patient care. The WCRN stated that the chemical indicator reflected that the instruments had been successfully sterilized and were acceptable for patient care. IP staff present provided additional education to the WCRN regarding the parameters of sterilization and steps needed to verify successful sterilization of instruments prior to use in patient care. 7.e. The CGIP, the ASIP and the IPONM confirmed Findings 7.a. and 7.b. at the time of the observation. 8.a. During a tour of EVS on 07/09/2024 with the DFNS, the ESS and the EVS Lead beginning at 1100, the following was observed: * The general appearance of the main EVS storage area was disorganized and cluttered. For example: - Five pieces of large cleaning equipment, which included floor buffing equipment and a wet/dry vacuum, blocked access to shelves where other supplies were stored. A large plastic garbage can was laying on its side on top of this group of equipment. - A set of covered metal shelves was sandwiched between the floor cleaning equipment and 4 carts. Two of the carts were empty, one cart contained a plastic bin with plastic spray bottles, and another cart held a large, uncovered garbage can with a “wet floor” sign. - The covered shelves contained a variety of items and it was unclear whether items were clean, dirty or in working order. Items included: mop buckets, an extension cord, a microwave, a housekeeping “Closed for Cleaning” sign, a plastic basket with unknown contents, 2 cardboard boxes with unknown contents and a piece of unknown equipment. Several carts had to be moved before the shelves could be accessed. - Patient care supplies, such as “bath tissue”, were stored in cardboard boxes in which the supplies had been shipped and dark gray residue as well as damage to the boxes were visible on the outside of the boxes, contrary to nationally recognized standards. Cardboard shipping containers may be susceptible to moisture, insects, and rodents or may have been exposed to contaminants during shipping. - A refrigerator located in this main EVS storage area contained a mixture of employee food items, food items with hospital labels and ~ one dozen boxes of assorted batteries for use in patient care equipment. Items for hospital use in patient care were not kept separate from employee personal items. * Across the hall from the main EVS storage area was a clean utility room which contained clean linens, and a variety of medical equipment. The storage area was disorganized and crowded. For example: - There were 6 linen carts of various sizes. Of the 6 carts, 3 carts were not fully covered and 2 of the 3 carts contained linen that was in direct contact with other smaller metal carts. A third cart was covered with plastic wrap with a “punched” through hole and a sheet that touched the floor. The bottom half of the carts, even those covered in plastic, were open to air. Additionally, when a smaller metal cart was moved away from one of the larger linen carts, a sheet was observed on the floor. - Infrequently used equipment that included 2 “code” carts, oxygen tanks, an IV pole with attached pump and other larger equipment were stored directly next to the carts, and toward the back and left-hand side of the room. There was not a clear separation of clean and dirty equipment. For example, 3 items were covered in plastic and of those 3, only one was tagged as “Clean” and dated. Other equipment was not similarly covered or identified as “Clean”. - A cart located next to the door was filled with CAPR equipment including ~ 2 dozen CAPR battery packs that were being charged. An unlabeled checklist sat on top of the batteries. It was unclear whether the cart items were clean. It was unclear who monitored, or how often the batteries were monitored. * Refillable chemical bottles, “Virex” and “Proxy” on various units throughout the hospital lacked expiration dates and it was unclear when the bottles had been filled or whether the disinfectants were viable. * A housekeeping cart contained small, plastic bottles filled with a clear liquid solution. The bottles lacked any identifiers such as type of cleaning solution or expiration date. The EVS staff indicated that these bottles were specific to the mops. * A dispensing unit for chemical disinfectants in the housekeeping closet required verification of MEC. An EVS staff member was asked to demonstrate how the MEC was validated for the hydrogen peroxide-based chemical. “Hydrogen Peroxide Indicator Strips” obtained with the intent to demonstrate testing reflected an expiration date of “Nov 1 2021”. * A container of “HR QAC QR Test Strips” for testing the quaternary disinfectant in the housekeeping closet was reviewed. The manufacturer’s IFUs reflected “NOTE: Sample must be at room temperature (above 75 [degrees])”. There was no thermometer present to indicate the temperature of the housekeeping closet or chemicals present. The ESS was asked what the temperature of the housekeeping closet was, and they stated, “69 or 70”. When asked whether there was a thermometer in the housekeeping closet, the ESS stated, “No.” * An EVS staff was asked to demonstrate daily cleaning of a patient care room and terminal cleaning of a patient care room. The EVS staff stated “The bed may be the first thing I clean depending on what the room looks like” such as equipment blocking access to the bed. The EVS staff stated, “Bed first, if room not filled with equipment” then “telesitter ... PT/OT commode ... things to be removed.” Additionally, they stated, “If there are too many things to move safely around the room, that would prompt me to do the bed last. Normally, the bed is cleaned first.” 8.b. During a tour of the hospital on 07/11/2024 with the ESS and Facility personnel beginning at 1000, the following was observed: * A cupboard located under the sink in the FNS kitchenette was screwed shut to prevent staff from storing items under the sink. The ESS was asked when the cupboard was last accessed, they stated “about a year ago” when the cupboards were first screwed shut. The ESS was asked whether the hospital regularly assessed that area for water leaks and the ESS confirmed that the cupboards under the sinks were not included in regular EOC rounding. Facility personnel removed the screw and under the sink was a large, coffee-colored stain and several splatter marks on the base and sides of the cupboard. Three other dark stains were noted directly under the sink’s P-trap and the back wall had a dark line running from the top of the cupboard to the base. A a small t-shaped metal valve was also noted. The Facility personnel present stated, “It looks like the coffee maker overflowed.” * Four additional sink cupboards were opened at the surveyor request and the following was observed: - Dust, small amounts of dirt, dried fluid residue and stains in 4 of 4 sink cupboards. - A large metal ring in one cupboard. - Plastic water bottle lids and peeling labels with dark residue in two cupboards. - An ant trap with hand-written dates of “6-12-07” and “7-10-07” sandwiched in a sink P-trap in one cupboard. 8.c. The ESS confirmed Findings 8.a. and 8.b. at the time of the observations. 9. During a tour of the Food and Nutrition Services kitchenette on 07/09/2024 beginning at 0945 the following was observed: * Condiments such as single serve butter, jelly, syrup, salad dressing, mustard, hot sauce, barbecue sauce, brown sugar topping and non-dairy creamer were stored in Ziploc bags with no expiration dates, or use by dates noted. * A clear plastic tote contained saltine crackers with no expiration date or use by date noted. * The inside top of microwaves contained visible food residue. * Cupboard shelves had printed labels that were smudged, worn and uncleanable. * A drawer contained several food grade thermometers. There were no instructions and it was unclear whether the thermometers were being used. The DFNS confirmed the observations at the time of the tour. The DFNS was asked whether the thermometers were used to monitor the temperature of patient food that was reheated in the microwaves and they stated they were not aware of that practice. The DFNS also acknowledged that there was no P&P in place for checking the temperature of reheated patient food prior to serving it.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (2) The infection prevention and control professional(s) is responsible for: (i) The development and implementation of facility-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 44104 The hospital failed to fully develop and implement infection prevention P&Ps in the following areas: * Hydrocollator cleaning procedures in Rehabilitation Services did not adhere to manufacturer’s IFUs. * Cleaning procedures of patient care instruments at point of use in the outpatient WCC did not adhere to nationally recognized standards and was not in accordance with hospital policy. Procedures for releasing sterilized instruments for use in patient care failed to adhere to nationally recognized standards. * Terminal cleaning of patient rooms by EVS staff did not adhere to nationally recognized standards or hospital training documents. * Chemicals for disinfection in secondary containers were not labeled in accordance with hospital policy. * Food available for patient consumption was not labeled in accordance with hospital policy. Findings include: 1. Refer to tag 1208, Findings 1.b., 2, 3.c., 3.b., 4.a., and 5; policies and procedures that were not fully developed, unclear and not fully implemented per nationally recognized standards. Refer also to Findings 6.a -9, facility observations where the hospital failed to implement Infection Prevention policies and procedures.”

“EP Program Patient Population CFR(s): §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: 42986 Based on document review and interview during the survey, it was determined through on-going dialog with the Systems Director, Director of Clinical Services, Facility Manager, and Emergency Management Manager, that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.625(a)(3)). Findings include: On 7/8/2024, during record review between 3:30 pm to 5:15 pm, the facility could not provide documentation within their written EP Plan that addressed patient/client population, including patients at risk and the types of services the facility has the ability to provide in an emergency. Surveyor was accompanied at exit by the Facility Administrator, Systems Director, Director of Clinical Services, Facilities Manager, and Emergency Management Manager who acknowledged the existence of these conditions.”

“Development of EP Policies and Procedures CFR(s): §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: 42986 Based on document review and interview during the survey, it was determined through on-going dialog with the System Director, Director of Clinical Services, Facilities Manager, and Emergency Management Manager that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.625(b)). Findings include: On 7/8/2024, during record review between 3:30 pm and 5:15 pm, the facility failed to develop and implement EP policies and procedures, based on the risks identified in the Hazards Vulnerability Assessment (HVA). The facility utilizes natural gas, however gas leaks was not identified as a risk on the HVA. The facility did not have a written policy or procedure for responding to a gas leak. Surveyor interviewed the Director of Clinical Services (DCS) (as the leader in charge during an emergency) regarding the response required in the event of a gas leak. When interviewed the DCS indicated she would call the maintenance staff. While surveyor provided education regarding items that need to be included in the response such as call 911, turn off the gas, and begin evacuation; the DCS responded that she did not know how to turn off the gas or where the gas shut off was located. Surveyor was accompanied at exit by the Facility Administrator, Systems Director, Director of Clinical Services, Facility Manager, and Emergency Management Director who acknowledged the existence of these conditions.”

“Subsistence Needs for Staff and Patients CFR(s): §403.748(b)(1), §418.113(b)(6)(iii), §441.184(b)(1), §460.84(b)(1), §482.15(b)(1), §483.73(b)(1), §483.475(b)(1), §485.542(b)(1), §485.625(b)(1) [(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal. This Standard is not met as evidenced by: 42986 Based on document review and interview during the survey, it was determined through on-going dialog with the Systems Director, Director of Clinical Services, Facility Manager and Emergency Management Manager that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.625(b)(1)). Findings include: On 7/8/2024, during record review between 3:30 pm and 5:15 pm, the facility failed to provide evidence of a secure and stable patient environment in the event of an elongated emergency, to include: (i) defined policies and/or protocols for medical, and pharmaceutical supplies of staff. Surveyor was accompanied at exit by the Facility Administrator, Systems Director, Director of Clinical Services, Facility Manager and Emergency Management Manager who acknowledged the existence of these conditions.”

“Procedures for Tracking of Staff and Patients CFR(s): §403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility’s] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF’s, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF’s, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees’ on-duty and sheltered patients in the hospice’s care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients. This Standard is not met as evidenced by: 42986 Based on observations and interview during the survey, it was determined through on-going dialog with the Systems Director, Director of Clinical Services, Facility Manager and Emergency Management Manager that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.625(b)(2)). Findings include: On 7/8/20224, during record review between 3:30 pm and 5:15 pm, the facility failed to provide a defined system to track the location of on-duty staff during an emergency. Surveyor was accompanied at exit by the Facility Administrator, Systems Director, Director of Clinical Services, Facility Manager and Emergency Management Manager who acknowledged the existence of these conditions.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 42986 Based on observations and interview during the survey, it was determined through on-going dialog with the Systems Director, Facility Manager and Emergency Management Manager that the facility failed to select, install, inspect and maintain fire extinguishers in accordance with adopted standards for universe all extinguishers of the facility. This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.12, NFPA 418 and NFPA 10). Findings include: On 7/9/2024, at 10:39, there was no documentation for monthly inspections for the portable fire extinguisher for the heliport at the hospital. The heliport is operated by Life Flight under contracted agreement with the facility on the hospital grounds. Surveyor was accompanied at exit by the Facility Administrator, Systems Director, Director of Clinical Services, Facilities Manager and Emergency Management Manager who acknowledged the existence of these conditions.”

“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: 42986 Based on observations and interview during the survey, it was determined through on-going dialog with the Systems Director, Facilities Manager and Emergency Management Manager that the facility failed to maintain/construct at least a 1-hour fire resistance rated smoke barrier for 2 of 3 sampled smoke compartments of the building. This resulted in the potential for the spread of fire/smoke to other smoke compartments (LSC 19.3.7.3, 19.3.7.4, 19.3.7.5 8.3, and 8.5). Findings include: 1. On 7/9/2024, at 10:35 am, there were multiple openings/penetrations in the ceiling of the Riser Room that was greater than 2 inches that would allow for the spread of smoke or fire to other areas of the facility. 2. On 7/9/2024, at 11:09 am, there were multiple openings/penetrations in the ceiling of Electrical Room 301080 near 100 clinic that was greater than 1/4 inch that would allow for the spread of smoke or fire to other areas of the facility. 3. On 7/9/2024, at 11:10 am, there were multiple openings/penetrations in the ceiling of 200 Electrical Room 301018 that was greater than 1/4 inch that would allow for the spread of smoke or fire to other areas of the facility. 4. On 7/9/2024, at 11:24 am, there were multiple openings/penetrations in the ceiling of the IDF Room that was greater than 1/4 inch that would allow for the spread of smoke or fire to other areas of the facility. 5. On 7/9/2024, at 11:25 am, there were multiple openings/penetrations in the ceiling of the UPS Room that was greater than 1/4 inch that would allow for the spread of smoke or fire to other areas of the facility. Surveyor was accompanied at exit by the Facility Administrator, Systems Director, Director of Clinical Services, Facilities Manager and Emergency Management Manager who acknowledged the existence of these conditions”