Collingsworth General Hospital

“A Life Safety Code (LSC) survey was conducted at Collingsworth General Hospital on 7/2/2025. An entrance conference was conducted on the morning of 7/2/2025 with the Chief Executive Officer (CEO), Director of Maintenance and the Director of Nursing (DON) to discuss the purpose of the LSC compliant and the survey process. 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. A LSC exit conference was conducted on the afternoon of 7/2/2025, with the CEO and Director of Maintenance, and DON. 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.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 29106 Based on review of the records and interview with the CEO and Director of Maintenance on the morning of 7/2/2025, the requirement for testing the Fire Alarm system is not met. It was indicated verbally it is tested during fire drills. No mention of activation of the alarm was listed on the report. It was also indicated testing is only done quarterly. The alarm must also be verified being sent and received at the monitoring station. No alarm logs were available at the time of inspection. Testing must be done monthly. Begin documenting testing.”

“Building Services - Other CFR(s): NFPA 101 Building Services - Other List in the REMARKS section any LSC Section 18.5 and 19.5 Building Services 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: 29106 Based on review of the records and interview with the CEO and Director of Maintenance on the morning of 7/2/2025, the requirement for final filter pressure drop records is not met. Based on records the filters are changed annually. No logs for monthly pressure readings were provided. Document readings.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 29106 Based observation during the walk of the facility with and interview with the Director of Maintenance on the morning of 7/2/2025, the facility failed to periodically exercise the main feeder and circuit breakers and had no records readily available. Begin logging this testing. “EPSS circuit breakers for Level 1 system usage, including main and feed breakers between the EPS and the transfer switch load terminals, shall be exercised annually with the EPS in the “off” position.” - NFPA 110, 2010, 8.4.7*. Note: “Circuit breakers should be tested under simulated overload conditions every 2 years.” - NFPA 110, 2010, A.8.4.7 NFPA 99, 2012, 6.4.4.1.2.1*. “Circuit Breakers. Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer’s recommendations.””

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 30250 Based on a review tour and interview, the facility failed to follow policy rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. Findings included: Facility policy entitled, “Disposable of Unusable Drugs Beyond Use Date” Reference Number 1596, state in part, “I. In all drug storage areas:... b. Expired drugs will be removed and returned to pharmacy for proper storage prior to reversal management company pick up or disposal.” During a tour of the facility on 06/24/25 in the nurse’s station medication room, the following medications were observed available for use: * 4 vials of Pneumococcal vaccine with an expiration date of 11/24/24. * 5 vials of Prevnar 13 vaccine with an expiration date of December 2024. In interview on 06/24/25, the nurse present in the medication room verified that the facility does provide vaccines to inpatients at the facility.”