Childress Regional Medical Center

“. An on-site Life Safety Code (LSC) Recertification Survey was conducted on 07/29/2026. An entrance conference was held for the Director of Maintenance, the Chief Operating Officer, and the Chief Executive Officer on the morning of 07/29/2026 to discuss the purpose of the LSC survey and the survey process was explained. Instructions were provided on writing plans of correction. An opportunity was provided for questions and discussion. The LSC survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, 42CFR482 to determine the Hospital ’ s compliance. An LSC exit conference was conducted on 07/29/2026 with Director of Maintenance and the Chief Executive Officer. The preliminary findings of the survey and the next steps in the survey process were explained. An opportunity was provided for questions and discussion. Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately. .”

“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: 35939 . K 372 Based on observations and interviews, the facility failed to maintain smoke barrier walls to resist the passage of smoke as required by NFPA 101, Life Safety Code, 19.3.7 and 8.5. This deficient practice could result in failure to contain toxic products of combustion to all smoke compartments, thus placing the patients, staff, and visitors of multiple smoke compartments in jeopardy in the event of a fire. The inspector observed, while accompanied by the Director of Maintenance and the Chief Executive Officer on 07/29/2026 from 1:10 AM to 1:50 PM, smoke barriers had unsealed penetrations, penetrations sealed with materials of unknown fire resistivity, penetrations sealed in a manner not consistent with firestopping systems/industry standards/manufacturer’s recommendations at the following locations: 1) The smoke barrier wall by Pharmacy and MRI. 2) The smoke barrier wall by 609 Central Clean-Up, OR, Surgical Services. 3) The smoke barrier wall by Nurses Station at Back of OR going into Labor and Delivery. Verify ALL rated construction is free of defects. In an interview at the time of each finding, the Director of Maintenance was informed of each deficiency, and he was able to observe the deficiencies. Code Reference(s): NFPA 101, 2012 edition 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following: (1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply: (a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c). (b) Not less than two separate smoke compartments shall be provided on each floor. (2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier. .”

“Evacuation and Relocation Plan CFR(s): NFPA 101 Evacuation and Relocation Plan There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2. 18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3 This Standard is not met as evidenced by: 35939 . K-711 Based on record review and interview, the facility failed to produce an updated copy of a written plan for the protection of all patients and for their evacuation in the event of an emergency in accordance with NFPA 101, 2012 edition, 19.7.2.1.2 and 19.2.2. The facility did not have an updated printed copy of a written evacuation plan. This deficient practice could result in a delayed evacuation in the event of an emergency, exposing patients to smoke inhalation, or other fire related injuries. Findings included: Record Review of the printed Disaster Procedure Manual presented by the CEO included sections/pages with outdated effective dates, including the “Medical Staff Department Directors & Committees” with an effective date of 10/01/2022 through 09/30/2024. In an interview on 07/29/2026 at approximately 1:55 PM the CEO was informed of the outdated material within the Disaster Procedures Manual. .”

“Gas and Vacuum Piped Systems - Maintenance Pr CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Maintenance Program Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040. 5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99) This Standard is not met as evidenced by: 35939 . K-907 Based on record review and interviews, the facility failed to ensure the medical gas system was maintained free of deficiencies. The medical gas system maintenance reports indicated there was an issue with the Medical Air Purity Test’s Dew Point. This deficient practice could expose patients to a faulty medical gas system. Findings included: Record review of the 2024 and 2025 “Annual Medical Gas & Vacuum Systems, Pipeline, and Equipment Inspection” report indicated the Medical Air Purity Test’s Dew Point had failed in both consecutive years. In an interview at the time of the record review, the Director of Maintenance was made aware of the failed item in the reports. .”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 35939 . K 914 Based on record review and interview, the facility failed to ensure hospital-grade AND non-hospital-grade receptacles at patient care locations were tested as required and records were maintained and available for review. There were no records available indicating receptacles in patient care areas have ever been tested. This deficient practice could result in receptacle malfunction in patient care areas, exposing patients to electrical shocks, smoke inhalation or other fire related injuries. Observations included: Record review during the inspection revealed there was no report to review inspection of electrical receptacles in all patient care areas. In an interview after the record review, the Director of Maintenance was informed of the missing document, and he was unable to provide any additional documentation indicating receptacles in patient care areas had been tested. Reference(s): NFPA 99, 2012 edition 6.3.4 Administration of Electrical System. 6.3.4.1 Maintenance and Testing of Electrical System. 6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. 6.3.4.1.4 The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators. 6.3.4.1.5 After any repair or renovation to an electrical distribution system, the LIM circuit shall be tested in accordance with 6.3.3.3.2. 6.3.4.2 Record Keeping. 6.3.4.2.1* General. 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification. 6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. .”

“COMPLIANCE WITH LAWS CFR(s): 482.11(a) The hospital must be in compliance with applicable Federal laws related to the health and safety of patients. This Standard is not met as evidenced by: 31690 Based on review of facility documents and staff interview, the facility failed to comply with local and state laws related to Title 26 505.141(g) to conduct at least 12 fire drills each year, one drill per shift per quarter, which shall include communication of alarms, simulation of evacuation and the use of fire fighting equipment. Findings were: Review of the faciity provided fire drill documentation reflected fire drills were conducted during the day shift in January, February, March, April and May 2026. There was no documentation of drills provided on the night shift. During an interview on the morning of 6/10/26, Staff #4, the Maintenance Director stated “There are 2 shifts at the hospital. 7 am to 7 pm and 7 pm to 7 am. I do four (4) fire drills on night shift per year and I do eight (8) fire drills on day shift per year. I do 12 fire drills a year and I make sure I do four (4) of them on the night shift every year.” Review of the facility policy titield “Fire Warning and Safety” effective 7/6/22 reflected in part, “...1. Hospital shall conduct at least 12 fire drills each year, one fire drill per shift per quarter, which shall include communication of alarms, simulation of evacuation of patients and other occupants, and use of fire fighting equipment...” Staff #4 confirmed there have been 0 fire drills conducted on night shift in 2026. Staff #4 confirmed there have been 5 fire drills completed in 2026 on the day shift. One in January, one in February, one in March, one in April and one in May, 2026.”

“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: 31690 Based on observation, interview, and record review the facility failed to ensure that the facility, supplies, and equipment were maintained to ensure an acceptable level of safety and quality. Both open supplies and supplies in the shipping corrugated boxes were observed in the large storage room. This could result in the clean open boxes contaminated by the corrugated card boxes that were shipped in to the facility. Findings included: In an article published by Spectrum Health in July 2014 it was stated “The heavier corrugated cardboard shipping boxes might harbor vermin or insects and spread the pests to areas where the boxes are stored after delivery. Corrugated cardboard boxes are not appropriate as storage units in medical or clean supply rooms. These boxes are not appropriate because they are an excellent harbor for insects and pests.” According to APIC: “Supplies must be: Removed from shipping cartons or cardboard boxes before storage to prevent contamination with soil/debris that may be on cartons ...Do not leave outer shipping boxes in clinical areas (due to risk of environmental contamination).” Preventing Infection in Ambulatory Care, Winter 2011/2012; available: http://apic.org/Resource_/TinyMecFileManager/Education/Preventing-In-in-Amb-Care-Winter2012-FINAL.PDF. Review of the facility policy Supply Receiving procedures Shelving Standards, last updated 6/1/2022 reflected the following: “ ... Shelving Standards: All supplies must be stored off the floor. Heavy-duty pallets or shelving units must keep items a minimum of 8 to 10 inches above the floor and at least 18 inches below ceiling sprinkler heads. Segregation: Clean and sterile supplies must be separated from soiled or hazardous materials ...” During a tour of the supply storage area on the afternoon of 06/9/26 multiple external shipping boxes, some still with the shipping labels, were observed stored on storage racks. There were also boxes of supplies on the shelving. Storage of supplies in this manner could potentially allow for dirt, debris, and pests from the outside shipping containers to contaminate supplies stored nearby. Staff # 23 verified these findings and reported that no outside shipping containers should be in the storage area.”