Wellspan Evangelical Community Hospital

“Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This Standard is not met as evidenced by: 32692 Based on observation and interview it was determined the facility failed to maintain the required fire resistance between floors, affecting two of four floors. Findings include: 1. Observation on November 5, 2024, at 12:20 p.m., revealed a four-inch PVC pipe through the basement ceiling outside the electrical office #0305 lacked a fire collar. Interview at the time of the exit conference with the Plant Engineering Operations Manager on November 5, 2024, at 1:00 p.m., confirmed the lack of an approved fire stop system for the PVC pipe penetration.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 32692 Based on observation and interview, it was determined the facility failed to maintain means of egress free and unobstructed on one of two floors. Findings include: 1. Observation on November 5, 2024, at 12:14 p.m., revealed wooden skids and storage containers were being stored in the lab corridors. Interview at the time of the exit conference with the Plant Engineering Operations Manager on November 5, 2024, at 1:00 p.m., confirmed the items were being stored in the corridors.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 32692 Based on observation and interview, it was determined the facility failed to maintain hazardous areas on three of four floors. Findings include; 1. Observation on November 5, 2024, between 9:30 a.m., and 12:17 p.m., revealed the following hazardous area doors failed to latch in the corresponding frame. a. At 9:30 a.m., 3rd floor, equipment storage room. b. At 11:15 a.m., 1st floor, storage room 1485. c. At 12:04 p.m., basement, transformer room 0835. d. At 12:17 p.m., basement, mechanical room 0311. Interview at the time of the exit conference with the Plant Engineering Operations Manager on November 5, 2024, at 1:00 p.m., confirmed the doors lacked positive latching. 2. Observation on November 5, 2024, at 12:28 p.m., revealed an unsealed pipe penetration around a 2 inch pipe near the single door #100 of the basement mechanical room. Interview at the time of the exit conference with the Plant Engineering Operations Manager on November 5, 2024, at 1:00 p.m., confirmed the space around the pipe was not sealed.”

“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: 32692 Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers on one of four floors. Findings include: 1. Observation on November 5, 2024, at 10:13 a.m., revealed a portable fire extinguisher outside room 2341 was blocked from immediate use by a bed. Interview at the time of the exit conference with the Plant Engineering Operations Manager on November 5, 2024, at 1:00 p.m., confirmed the bed was blocking access to the fire extinguisher.”

“Corridors - Construction of Walls CFR(s): NFPA 101 Corridors - Construction of Walls 2012 EXISTING Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames. If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area. 19.3.6.2, 19.3.6.2.7 This Standard is not met as evidenced by: 32692 Based on observation and interview, it was determined the facility failed to maintian the required smoke resistance of corridor walls on one of four floors. Findings include: 1. Observation on November 5, 2024, at 12:30 p.m., revealed a pipe penetration of the corridor wall near door d0140 in the basement IT department. Interview at the time of the exit conference with the Plant Engineering Operations Manager on November 5, 2024, at 1:00 p.m., confirmed the pipe penetration was not sealed.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 50182 Based on observation and interview, it was determined the facility failed to maintain corridor openings on two of four floors. Findings include: 1. Observation on November 5, 2024, between 10:00 a.m., and 12:17 p.m., revealed the following: a. At 10:00 a.m., Room 2202 not smoke tight. b. At 10:05 a.m., Room 2206 failed to latch. c. At 10:39 a.m., Room 2502 not smoke tight. d. At 12:17 p.m., Basement level, Biomedical room door, was warped and could not properly close into corresponding frame Interview at the time of the exit conference with the Plant Engineering Operations Manager on November 5, 2024, at 1:00 p.m., confirmed the corridor opening deficiencies.”

“Gas and Vacuum Piped Systems - Other CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Other List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 5 (NFPA 99) This Standard is not met as evidenced by: 32692 Based on observation and interview, it was determined the facility failed to maintain the piped in medical gas system on one of four floors. Findings include: 1. Observation on November 5, 2024, at 12:02 p.m., revealed steel metallic cabling in contact with a copper medical gas line in mechanical room 0813. Interview at the time of the exit conference with the Plant Engineering Operations Manager on November 5, 2024, at 1:00 p.m., confirmed the steel cabling in contact with the copper pipe.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 32692 Based on observation and interview, it was determined the facility failed to maintain the electrical system wiring components on one of four floors. Findings include: 1. Observation on November 5, 2024, at 10:13 a.m., revealed an open junction box in room 2335, 2nd floor. Interview at the time of the exit conference with the Plant Engineering Operations Manager on November 5, 2024, at 1:00 p.m., confirmed the junction box lacked a cover.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 32692 Based on observation and interview, it was determined the facility failed to monitor for the unauthorized use of multiple outlet power taps. Findings include: 1. Observation on November 5, 2024, at 11:10 a.m., pharmacy on the 1st floor, multiple outlet power tap was powering several small appliances. Interview at the time of the exit conference with the Plant Engineering Operations Manager on November 5, 2024, at 1:00 p.m., confirmed the power tap was powering non-electronic appliances.”

“LICENSURE OF PERSONNEL CFR(s): 482.11(c) The hospital must assure that personnel are licensed or meet other applicable standards that are required by State or local laws. This Standard is not met as evidenced by: 48679 Based on review of facility documents, personnel files (PF) and staff interview (EMP), it was determined one of thirteen personnel files did not include all required documents per the job description (PF10). Evangelical Community Hospital. American Heart Association Life Support Training. “POLICY: Hospital job descriptions designate which positions require Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS). The Hospital abides by evidence informed resuscitation practices recognized by the International Liaison Committee on Resuscitation (ILCOR). The Hospital accepts resuscitation credentials awarded through the American Red Cross (ARC), American Heart Association (AHA), or other organizations that provide training administered in accordance with the AHA and/or ILCOR guidelines. For the convenience of employees, the Hospital provides access to online ARC certification through (name of educational provider)”. Job description labeled “Nursing Coordinator Acute Care ... Qualifications ... 3. BLS and ACLS, are required. ... “ Review of PF10 on October 31, 2024, revealed PF10 contained a job description for Nursing Coordinator Acute Care signed and dated October 29, 2024. PF10 did not contain the required ACLS documentation. Interview with EMP4 and EMP13 on October 31, 2024, at 1100 confirmed the findings noted above.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) [Unless superseded by State law that is more restrictive,] (iii) Each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy. This Standard is not met as evidenced by: 32337 Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure an order for restraint was obtained for non-violent restraint use in two of two medical records reviewed (MR74 and MR75). Findings include: Review on October 31, 2024 of the facility policy “Physical Restraints/Chemical Restraints,” last reviewed April 10, 2024, revealed “Purpose: The purpose of this policy is to 1. prevent interference/obstruction with medical treatment (such as self extubation and intubation). 2. protect medical devices (such as intravenous lines, in-dwelling urinary catheters, and feeding tubes). 3. prevent falls and injury. 4. control disruptive behavior (such as agitation, wandering, and combativeness). 5. prelude the possibility of harming self, staff and other patients. ... Procedures: ... 2. Use of Restraints in Medical or Post-Surgical Care: a) When clinically indicated, the restraint procedure is implemented by an RN who is trained in restraint technique upon a physician’s/L.I.P. (Licensed Independent Practitioner) order. Physician/L.I.P. may delegate ordering restraint to physician assistant or advance practice nurse in both behavioral health and acute care non-behavioral health care settings. ... d) A restraint order expires after 24 hours and must be reordered if restraints continue to be required. ...” Review on October 31, 2024 of MR74 revealed the patient had bilateral soft wrist restraints in place beginning January 1, 2024, at 0949, and discontinued January 10, 2024, at 1200. Documentation noted restraints orders on January 1, 2024, at 0949, January 2, 2024, at 1041, and January 3, 2024, at 0947. There were no orders for restraint use on January 4, 2024, January 5, 2024, January 6, 2024, January 7, 2024, January 8, 2024, January 9, 2024, or January 10, 2024. Interview with EMP1 and EMP4 on October 31, 2024, at 1323, confirmed the findings noted above in MR74. EMP1 confirmed the restraint order on January 2, 2024, at 1041, was later than the 24- hour time frame. Review on October 31, 2024 of MR75 revealed the patient had bilateral soft wrist restraints in place beginning January 5, 2024, at 0944, and discontinued January 16, 2024, at 2330. Documentation noted restraint orders on January 5, 2024, at 0944, January 6, 2024, at 1251, January 7, 2024, at 0738, January 8, 2024, at 0958, January 9, 2024, at 1004, January 10, 2024, at 0816, January 11, 2024, at 1017, January 12, 2024, at 0826, January 13, 2024, at 1113, January 14, 2024, at 1119, January 15, 2024, at 1019, and January 16, 2024, at 0906. Interview with EMP1 and EMP4 on October 31, 2024, at 1335, confirmed the findings noted above in MR75. EMP1 confirmed the restraint orders on January 6, 2024, at 1251, January 8, 2024, at 0958, January 9, 2024, at 1004, January 11, 2024, at 1017, January 13, 2024, and at 1113, January 14, 2024, at 1119, were ordered later than the 24-hour time frame.”

“DIRECTOR OF DIETARY SERVICES CFR(s): 482.28(a)(1) The hospital must have a full-time employee who- (i) Serves as director of the food and dietetic services; (ii) Is responsible for daily management of the dietary services; and (iii) Is qualified by experience or training. This Standard is not met as evidenced by: 18754 Based on observation, review of facility policy and dish machine temperature logs, and staff (EMP) interview, it was determined the facility failed to ensure dietary supervisory staff monitored the dish washer temperature logs and intervened when final dish washer rinse temperatures did not meet minimum temperatures for sanitation in forty-five (45) of ninety (90) days reviewed. Findings include: Review on October 29, 2024, of “ Dishwashing and Flatware Washing “ policy, last reviewed by the facility on November 10, 2023, revealed: “ Purpose: To assure that all dishes and flatware are properly cleaned and sanitized to maintain the health and well-being of clients. Dish machine temperatures of wash, rinse, and surface are recorded three times daily on the Temperature Log. If temperatures are below minimum, staff will notify Director, Operations Manager, Cook, or Plant Engineering Department. ... “ Tour and observation conducted on October 29, 2024, at 1050 of the dietary services department revealed the October dishwasher temperature monitoring log located in the dishwasher area. Review of the Dish Machine Temperature Monitoring Chart for October 2024 revealed the dishwasher did not reach the minimum final rinse temperatures (temp) of 180 degrees Fahrenheit (F) on the following dates: October 1, 2024 (9:00 A.M. temp 179F, 6:00 P.M. temp 171F), October 8, 2024 (6:00 P.M. temp 177F), October 9, 2024 (6:00 P.M. temp 179F), October 13, 2024 (6:00 P.M. temp 172F), October 14, 2024 (6:00 P.M. temp 173F), October 15, 2024 (6:00 P.M. temp 168F), October 16, 2024 (6:00 P.M. temp 169F), October 23, 2024 (6:00 P.M. temp 179F), October 24, 2024 (6:00 P.M. temp 159F), and October 28, 2024 (1:00 P.M. temp 179F and 6:00 PM temp 178F). There was no indication of interventions taken for the dishwasher not meeting minimum temperatures during the final rinse documented on the log. Review on October 29, 2024, at approximately 1100, of the Dish Machine Temperature Monitoring Chart for September 2024 revealed the dishwasher did not reach the minimum final rinse temperatures (temp) of 180 degrees Fahrenheit (F) on the following dates: September 5, 2024 (6:00 P.M. temp 179F), September 7, 2024 (9:00 AM temp 172F), September 8, 2024 (1:00 P.M. temp 170F), September 11, 2024 (6:00 P.M. temp 173F), September 12, 2024 (6:00 P.M. temp 169F), September 13, 2024 (6:00 P.M. temp 173F), September 14, 2024 (6:00 P.M. temp 178F), September 16, 2024 (1:00 P.M. temp 177F), September 17, 2024 (1:00 P.M. temp 179F and 6:00 P.M. temp 171F), September 19, 2024 (6:00 P.M. temp 176F), September 20, 2024 (1:00 P.M. temp 179F), September 23, 2024 (6:00 P.M. temp 176F), September 24, 2024 (6:00 P.M. temp 178F), September 27, 2024 (1:00 P.M. temp 179F) and September 28, 2024 (1:00 P.M. temp 170F). There was no indication of interventions taken for the dishwasher not meeting minimum temperatures during the final rinse documented on the log. Review on October 29, 2024, at approximately 1105, of the Dish Machine Temperature Monitoring Chart for August 2024 revealed the dishwasher did not reach the minimum final rinse temperatures (temp) of 180 degrees Fahrenheit (F) on the following dates: August 3, 2024 (9:00 A.M. temp 170F), August 6, 2024 (1:00 P.M. temp 177F and 6:00 P.M. temp 174F), August 7, 2024 (1:00 P.M. temp 173F and 6:00 P.M. temp 172F), August 8, 2024 (6:00 P.M. temp 170F), August 9, 2024 (6:00 P.M. temp 170F), August 12, 2024 (9:00 A.M. temp 160F), August 13, 2024 (9:00 A.M. temp 160F and 6:00 P.M. temp 171F), August 14, 2024 (9:00 A.M. temp 177F), August 15, 2024 (9:00 A.M. temp 178F), August 16, 2024 (9:00 A.M. temp 176F), August 17, 2024 (9:00 A.M. temp 170F), August 21, 2024 (9:00 A.M. temp 170F and 6:00 P.M. temp 170F), August 22, 2024 (9:00 A.M. temp 170F and 6:00 P.M. temp 172F), August 23, 2024 (9:00 A.M. temp 171F), August 24, 2024 (9:00 A.M. temp 172F), August 25, 2024 (9:00 A.M. temp 170F), August 26, 2024 (9:00 A.M. temp 170F and 6:00 P.M. temp 175F), August 27, 2024 (9:00 A.M. temp 170F and 6:00 P.M. temp 176F), August 28, 2024 (9:00 A.M. temp 170F and 6:00 P.M. temp 178F) and August 29, 2024 (9:00 A.M. temp 170F and 6:00 P.M. temp 171F). There was no indication of interventions taken for the dishwasher not meeting minimum temperatures during the final rinse documented on the log. Interview with EMP6 on October 29, 2024, at approximately 1125 confirmed the above findings. EMP6 stated they realized about a week ago the dishwasher wasn’t maintaining minimum final rinse temperatures. EMP6 revealed Plant Engineering was contacted on October 29, 2024 to fix the dishwasher. EMP6 stated it was EMP5 and EMP6’s responsibility to oversee the Dish Machine Temperature Monitoring Chart logs.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 32337 Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure safety was maintained with temperature monitoring on a hot pack and a cold pack machine. Findings include: Review on October 31, 2024 of the facility policy “Hydra Therm Hot Packs “ last reviewed March 15, 2024, revealed “Purpose: To ensure patient safety when receiving heat therapy. To ensure staff safety in the utilization of Heat Therapy using Hydra Therm hot packs and machine. To ensure staff are appropriately preparing for application of heat therapy. To ensure proper care of the equipment. Policy: The Rehabilitation Staff will adhere to the stated protocol and listed procedures when administering Heat therapy as a component of patient care. Procedure: ... 5. Care of Equipment: ... e. The hydrocollator should be emptied, thoroughly cleaned, and refilled every 3 months or sooner, if water discoloration occurs.” Review on October 31, 2024 of the facility policy, “Cold Pack Utilization and Cleaning, last reviewed January 10, 2024, revealed “Purpose: To ensure safe utilization of cold packs in cryotherapy in the treatment of patients and to ensure proper maintenance of equipment. ... Procedures: The rehabilitation staff will proceed with the following outlined procedures in the application of cold therapy, utilizing cold packs. ...7. Care of Equipment ... d. The cooling unit/freezer should be cleaned every 30 days.” Review on October 31, 2024 of the “Hydrotherm Daily Cleaning Log,” for January 1, 2024-October 31, 2024 revealed the equipment was last cleaned on March 31, 2024. Interview with EMP14 on October 31, 2024, at 1400, confirmed the findings noted above for the Hydrotherm Daily Cleaning Log. Review on October 31, 2024 of the “Cold Pack Daily Cleaning Log,” for January 1, 2024-October 31, 2024 revealed the equipment was not cleaned for the months of January, February, March, May, July, August or October 2024. Interview with EMP14 on October 31, 2024, at 1415, confirmed the findings noted above for the Cold Pack Daily Cleaning Log.”

“STANDARD TAG FOR OUTPATIENT SERVICES CFR(s): 482.54 Standard-level Tag for §482.54 Condition of Participation: Outpatient Services If the hospital provides outpatient services, the services must meet the needs of the patients in accordance with acceptable standards of practice. This Standard is not met as evidenced by: 18754 Based on observation, review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure that outpatients had signed general consent to healthcare services form (which contains consent to treatment, patient rights and responsibilities, authorization of billing/financial responsibility, advanced directives, and receipt of notice of privacy practices) prior to providing services in four (4) of four (4) MRs reviewed for the West Branch outpatient phlebotomy area. (MR70, MR71, MR72 and MR73). Findings include: Review on October 31, 2024, of facility policy “ Registration General Consent, “ reviewed on July 11, 2024, revealed: “ Purpose: Requirements for obtaining general consent for treatment from patients. Policy: During the registration process and prior to the service being provided the General Consent for Health Care Services for [sic] is reviewed with and signed by the patient (or the patient’s Authorized Representative and is witnessed by staff ... Procedures: Obtaining Signature on General Consent for Treatment 1. As part of the registration/admitting process, the General Consent for Treatment must be signed by each patient or his/her legally authorized representative upon each encounter and scanned into [name of computer program] ... b) If the patient is unable to consent, obtain consent from a legally authorized representative. c) If a patient otherwise capable of giving valid consent is unable to write, the patient may make his or her mark on the line designated for a signature or may otherwise communicate consent in a manner acceptable to the physician. Such consent shall occur in the presence of two witnesses d) If a patient is unable to sign, and no legally authorized representative is present, verbal consent may be obtained and documented as such on the form in the presence of two witnesses. ... 2. If the patient or his/her Authorized Representative refuses to sign this consent, the issue should be referred to the appropriate manager for resolution. 3. When consent is due but not obtained prior to a patient ’ s visit or admission, the registration/admitting staff are responsible for following-up and obtaining consent as soon as possible and prior to the patient ’ s discharge. If, following good faith efforts, the staff is still unable to obtain consent, staff must enter the reason in the notes section of the registration system. ... “ Tour and observation conducted on October 31, 2024, at 1110 with EMP2 and EMP5 at the hospital-based provider location West Branch outpatient phlebotomy revealed MR70 in the phlebotomy registration area. MR70 then proceeded to the phlebotomy area. This surveyor observed staff request insurance information and check for a provider order. This surveyor did not observe MR70 sign a consent to health care services form prior to phlebotomy service. After MR70 left, this surveyor requested to see the forms completed for the registration process. There was no general consent for health care services form signed for the service. During the time of the tour, EMP5 stated staff only ask for the physician’s order (if a physical form) and insurance cards at this location. EMP5 confirmed pre-registration does not occur elsewhere. EMP5 confirmed there was no general consent for health care services form in MR70. Interview on October 31, 2024, with EMP10 at 1131, and EMP11 at 1147, confirmed there was no general consent for health care services form completed by the West Branch outpatient phlebotomy site. EMP10 stated that the patient coming to the location was their consent. EMP11 stated there was no registration clerk at this location. Review of additional West Branch outpatient phlebotomy MRs with EMP5 on October 31, 2024, at 1249, revealed the following: Review of MR71 contained physician orders for the labs drawn on October 31, 2024. There was no general consent for health care services form completed. Review of MR72 contained physician orders for the labs drawn on October 31, 2024. There was no general consent for health care services form completed. Review of MR73 contained physician orders for the labs drawn on October 31, 2024. There was no general consent for health care services form completed. Interview with EMP5 on October 31, 2024, at the time of MR review, confirmed the findings noted above. Tour and observation were conducted on October 31, 2024, at 1221 with EMP2 of the Central Registration area which included registration for the main hospital’s outpatient phlebotomy patients. Interview on October 31, 2024, at 1221 with EMP12 revealed that for every visit the patient would complete the general consent for health care services form. Review of this form contained the following items: consent to treatment, patient rights and responsibilities, authorization of billing/financial responsibility, advanced directives, and receipt of notice of privacy practices. EMP12 also indicated if the patient was new to the facility, registration staff would also review the acknowledgement of notice of privacy practices, and universal authorization for the release of sensitive medical information forms.”