Iraan General Hospital

“COMPLIANCE STATE AND LOCAL LAWS AND REGS CFR(s): All patient care services are furnished in accordance with applicable State and local laws and regulations. This Standard is not met as evidenced by: 31690 Based on observation, interview, and record review, the facility failed to A. maintain and meet the standards at Texas Administrative Code, Title 26 section 505.41 (d)(1)(A), when the facility’s Dietary Manager failed to have current Food Service Manager certification and B. failed to comply with Title 26 505.141(g) to (g) conduct at least 12 fire drills each year, one drill per shift per quarter, which shall include communication of alarms, simulation of evacuation of patients and other occupants, and the use of fire fighting equipment. Findings include: A. Review of the Texas Administrative Code, Title 26 section 505.41 (d)(1)(A) reflects the following: “(A) The hospital shall have a full-time employee who is qualified by experience or training to serve as director of the food and dietetic service and be responsible for the daily management of the dietary services.” Review of the facility policy “Dietary Manager Job Description” last revised 10/31/24 reflected no reference to having Food Service Manager course completion. During a telephone interview, on the evening of 3/18/26 Staff # 6 reported that she had not been aware of the requirement that she have taken the Food Service Manager certification course. She continued that after being made aware of the requirement, she completed the course today. During an interview, on the afternoon of 3/18/26 Staff #1 reported that he was unaware of this issue. B. Review of the facility’s documentation pertaining to fire drills revealed “Fire Drill” report Date: 9/29/25, Time 16:00, Number of participants 26...Date 1/16/26 Time 20:00, Number of participants 4...Sign in sheets reflected signatures of 3 participants 1/16/26 at 8:09 pm, 26 participants 9/29/25 at 3:32 (no documentation of am or pm), and 28 participants on 6/5/25 at 1:45 pm. During an interview during the entrance conference 3/16/26, Staff #1, the Chief Executive officer stated Staff #12 is the facility’s Safety Officer. During an interview 3/18/25, Staff #12 the Emergency Preparedness Coordinator confirmed he does one fire drill for one shift per quarter. He stated one fire drill was done in September of 2025 in the afternoon and one fire drill was done in January 2026 on the night shift.”

“INFECTION PREVENT & CONTROL ORG & POLICIES CFR(s): Infection prevention and control program organization and policies. The CAH must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body, or responsible individual, as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 31690 Based on interviews and facility documents, the facility failed to have an individual who is qualified through training or certification in infection prevention and control, responsible for the infection prevention and control program. Findings were: In an interview on the morning of 3/17/26, in a facility conference room, Chief Nursing Officer (CNO) and Infection Control Coordinator (ICC), Staff #2, reported she held neither credential nor certification in Infection Prevention and Control. “ ... I have been looking for a course that I can take and have reached out to professional contacts for information. Review of the Chief Nursing Officer’s Job Description, signed on 2/11/25, reflected in part “Maintains Infection Control Program.” There was no job description for the Infection Control Coordinator provided. The above information was verified by both Staff #1 and Staff #2 on the afternoon of 3/17/26.”

“A Life Safety Code (LSC) Re-Certification Survey was conducted at site on 07/09/25. An entrance conference was held for the CEO and Plant Operations Director on 07/09/25 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 07/09/25 in the hospital, attended by the Plant Operations Manager. 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.”

“General Requirements - Other CFR(s): NFPA 101 General Requirements - Other List in the REMARKS section any LSC Section 18.1 and 19.1 General 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. This Standard is not met as evidenced by: 31947 Based on observation and testing of the Nurse Calling System, the facility failed to provide a fully functioning system that allows communications between patients, distress and emergencies to first responders and staff. Please provide a letter of completion and approval of the Nurse Calling System from the Manufacturer/Installer stating that all is well and that all identifying locations match installed room signage, as required by: Department of State Health Services, Title 25 Texas Administrative Code, Chapter 133, Hospital Licensing Rules, Effective June 21, 2007, Amended December 9, 2010 §133.2; §133.41(e),(f),(g),(o),(t),(w); §133.49; §133.163(bb), Amended November 11, 2012 §133.2; §133.41(b),(c),(f),(j),(l), Amended May 24, 2013 §133.41(f),(r), Amended September 14, 2014 §133.2(18); §133.41(e),(f),(j),(o); §133.45(g) (L) Nurses calling systems. Three different types of nurses calling systems are required to be installed in a hospital: a nurses regular calling system; a nurses emergency calling system; and a staff emergency assistance calling system. The hospital shall comply with the requirements of this subparagraph in addition to any specific requirements for nurses calling systems for the particular unit of the hospital in accordance with §133.163 and Table 7 of §133.169(g) of this title. Where required in this subparagraph, a distinct visible signal is provided when a colored dome light lamp, or particular combination of colored lamps is used for only one type of call. Different flash rates do not meet this requirement. (i) A nurses regular calling system is intended for routine communication between each patient and the nursing staff. Activation of the system at a patient’s regular calling station will sound a repeating (every 20 seconds or less) distinct audible signal at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. The audible signal shall be canceled and two-way voice communication between the patient room and the nursing staff shall be established at the unit’s nursing station when the call is answered by the nursing staff. The visible signal(s) in the corridor shall be canceled upon termination of the call. Calls shall activate visible signals in accordance with Table 7 of §133.169(g) of this title. An alarm shall activate at the nurses station when the call cable is unplugged. (ii) A nurses emergency calling system shall be installed in all toilets used by patients to summon nursing staff in an emergency. Activation of the system shall sound a repeating (every 5 seconds or less) a distinct audible signal at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. The visible and audible signals shall be cancelable only at the patient calling station. Calls shall activate visible signals in accordance with Table 7 of §133.169(g) of this title. When conveniently located and accessible from both the bathing and toilet fixtures, one emergency call station may serve one bathroom. A nurses emergency call system shall be accessible to a collapsed patient lying on the floor. Inclusion of a pull cord extending to within six inches of the floor will satisfy this requirement. (iii) A staff emergency assistance calling system (code blue) is intended to be used by staff to summon additional help in an emergency. In open suites, an emergency assistant call system device shall be located at the head of each bed and in each individual room. The emergency assistance calling device can be shared between two beds if conveniently located. Activation of the system will sound a distinct audible signal at the nursing unit’s nurses station or at a staffed control station of a suite, department or unit, indicate type and location of call on the system monitor and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. Calls shall activate audible and visible signals in accordance with Table 7 of §133.169(g) of this title. A visible system shall clearly define the alarm location to a continuously staffed back up area (other than the nurse station or an administrative center) from which assistance can be summoned. Alternatively, back up may be provided via automatic annunciation from the staff emergency assistance calling system through wireless phones or pagers. The system shall have voice communication capability so that the type of emergency or help required may be specified between the point of alarm and the unit’s nurse station.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 31947 Based on observation and testing of required door closers and fire rating, the facility failed to provide proper labeling, latching and/or door closures at all required locations. Please verify all doors and frames at rated walls have the proper rating and hardware and that all rated walls are installed, which is not the case at the new storage room in the Physical Therapy Department. Please be informed that all storage rooms over 100 square feet shall be one-hour rated, as required by: Department of State Health Services, Title 25 Texas Administrative Code, Chapter 133, Hospital Licensing Rules, Effective June 21, 2007, Amended December 9, 2010 §133.2; §133.41(e),(f),(g),(o),(t),(w); §133.49; §133.163(bb), Amended November 11, 2012 §133.2; §133.41(b),(c),(f),(j),(l), Amended May 24, 2013 §133.41(f),(r), Amended September 14, 2014 §133.2(18); §133.41(e),(f),(j),(o); §133.45(g) (xiv) Fire doors. All fire doors shall be listed by an independent testing laboratory and shall meet the construction requirements for fire doors in National Fire Protection Association 80, Standard for Fire Doors and Fire Windows, 1999 edition. Reference to a labeled door shall be construed to include labeled frame and hardware. (III) The door to each seclusion room shall have no hardware on the room side and shall open out. A vision panel shall be provided in each door to permit staff observation of the entire room while maintaining privacy from the public and other patients. NFPA 101: 18.3.2.1 ..... Any hazardous areas shall be protected in accordance with Section 8.7, and the areas described in Table 18.3.2.1 shall be protected as indicated. The doors shall be a minimum ¾ hour fire rated doors set in rated frames. With that classification, the door’s hardware, including door closers device and latching hardware, must meet the requirement for storage rooms. NFPA 101, 8.7.1.3 .....Doors in barriers required to have a fire resistance rating shall have a ¾ hour fire protection rating and shall be self-closing or automatic closing in accordance with 7.2.1.8.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 31947 Based on observation and testing of the Mechanical Exhaust System, the facility failed to provide a fully functioning system that allows proper ventilation at all required spaces. Please provide a new new Test Air Balance Report for the entire facility indicating no failures and a letter of approval review of the Test Air Balance Report from the Mechanical Engineer of Record along with a letter that the entire MEP system is functining correctly, as required by: Department of State Health Services, Title 25 Texas Administrative Code, Chapter 133, Hospital Licensing Rules, Effective June 21, 2007, Amended December 9, 2010 §133.2; §133.41(e),(f),(g),(o),(t),(w); §133.49; §133.163(bb), Amended November 11, 2012 §133.2; §133.41(b),(c),(f),(j),(l), Amended May 24, 2013 §133.41(f),(r), Amended September 14, 2014 §133.2(18); §133.41(e),(f),(j),(o); §133.45(g) (3) General mechanical requirements. This paragraph contains common requirements for mechanical systems; steam and hot and cold water systems; air conditioning, heating and ventilating systems; plumbing fixtures; piping systems; and thermal and acoustical insulation. The hospital shall comply with the requirements of this paragraph and any specific mechanical requirements for the particular unit of the hospital in accordance with §133.163 of this title. (C) Performance and acceptance. Prior to completion and acceptance of the facility, all mechanical systems shall be tested, balanced, and operated to demonstrate to the design engineer or his representative that the installation and performance of these systems conform to the requirements of the plans and specifications. (VI) Directional air flow. Ventilation systems shall be designed and balanced to provide directional flow as shown in Table 3 of §133.169(c) of this title. For reductions and shutdown of ventilation systems when a room is unoccupied, the provisions in Note 4 of Table 3 of §133.169(c) of this title shall be followed. To satisfy exhaust needs, replacement air from the outside is necessary. Table 3 does not attempt to describe specific amounts of outside air to be supplied to individual spaces except for certain areas such as those listed. Distribution of the outside air, added to the system to balance required exhaust, shall be as required by good engineering practice. Minimum outside air quantities shall remain constant while the system is in operation. In variable volume systems, the minimum outside air setting on the air handling unit shall be calculated using the ASHRAE Standard 62.1, 2004 edition.”