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Based on document reviews and interviews the hospital failed to maintain the temperature and humidity in the procedure rooms and the ("CSR") Central Sterile Room, according to the 2025 Association of periOperative Registered Nurses ("AORN") standards, the standards that the hospital adopted.

Findings:

The 2025 Association of periOperative Registered Nurses ("AORN") Edition page 103 contains standards related to temperature and humidity in the following areas: Procedure Rooms 20% to 60% humidity; Sterile Processing Clean Assembly Workroom maximum 60% humidity and temperature 68 to 73 degrees Fahrenheit.

1. The Houlton Regional Hospital policy titled, Temperature and Humidity in the OR, last reviewed 3/24/2025, stated in part, "In the event that temperature and humidity readings are not within the recommended range in the operating room, the charge nurse will notify the surgeon assigned to the case ...Documentation of notification will occur on the Temperature and Humidity log sheet. Maintenance work order will be placed for temperature or humidity readings outside the recommended ranges in OR's".

On 4/24/2025 at 12:19 PM, an interview was conducted with the Maintenance Manager, regarding the documentation of the Operating Rooms Temperatures and Humidity. He stated it is done on a daily basis. He shared todays (4/24/2025) documentation but yesterday's (4/23/2025) documentation was unavailable due to the person who is responsible for documenting that information was not there yesterday to record it. He also stated that he does not have last weeks documentation as that person was on vacation. He stated that until today there was only person trained to do that job. He stated that another person has been trained to do that job as of 4/24/2025.

On 4/24/2025 at approximately 2:40 PM, the temperature and humidity log for Operating Rooms was reviewed. This review revealed that on 4/24/2025, the humidity for Procedure Room A was 0%, Procedure Room B was 19% and Procedure Room C was 19%. There was no documentation of notification to the surgeon assigned to the cased of these results as required by the hospital policy titled "Temperature and Humidity in the OR".

2. There was no policy that identified what the hospital would do in the event that the temperature and humidity in the Central Sterile Room were not within the recommended range as outlined in the 2025 Association of periOperative Registered Nurses ("AORN") Edition page 103 where standards related to temperature and humidity in the Sterile Processing Clean Assembly Workroom, outlined maximum 60% humidity and temperature 68 to 73 degrees Fahrenheit.

On 4/24/2025, at 2:42 PM, the temperature and humidity logs for Central Sterile for September 2024 thru April 2025 were reviewed. This review revealed that five (5) days in September 2024, one (1) day in October 2024, three (3) days in November 2024, two (2) days in March 2025 and five (5) days in April 2025, there was no temperature or humidity documented.

On 4/25/2025, at approximately 10:00 AM, an interview was conducted with the Central Sterile Technician ("CST"). She was asked if she completed the documentation of the temperature and humidity logs for Central Sterile from September 2024 thru April 2025 and she stated yes. She stated that the sixteen (16) days throughout that time where there was no documentation was because she was not working then and no one recorded the temperature or humidity on the log.

Based on document reviews, observations and interviews, the hospital failed to ensure that 1.) Construction was completed using their infection control risk assessment for one (1) of one (1) mechanical room renovation and 2.) Staff were adhering to the surgical attire while in the central sterile area for one (1) of one (1) central sterile technicians and an Operating Room Registered Nurse.

Findings:

The Houlton Regional Hospital ("HRH") Infection Prevention and Control Department "Construction and Renovations (102B)" policy, last reviewed 07/2024, states in part, " ...When planning construction or renovation projects, Infection Control issues need to be considered to assure that infection risks are minimized before, during, and after the project is completed ... Construction performed by employees of HRH, and outside contractors/sub-contractors ...Construction activity types are defined by the amount of dust generated, the duration of the activity, and the amount of shared HVAC [Heat, Ventilation, Air Conditioning] systems. Staff should contact the Infection Prevention and Control Department (Ext. 2340) if any activity is questionable under these guidelines ... Type C Any work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies. Includes by not limited to, sanding of walls for painting or wall covering, removal of floor coverings, ceiling tiles and casework, new wall construction, minor ductwork or electrical work above ceilings, major cabling activities, and any activity that cannot be completed within a single work shift ... ."


1. Construction and Renovation
- On 4/23/2025 at approximately 12:00 PM, State Fire Marshall Office ("SFMO") notified Survey Team Leader of issues the team had identified in the Central Sterile and adjacent Mechanical Room. Surveyors observed multiple gaps around two (2) sterilizers, non-intact walls, and multiple non-intact areas with significant debris in the ceiling.

- On 4/24/2025 at approximately 12:23 PM, the Director of Engineering/Maintenance stated they removed a low pressure steam system and two reserve tanks. They were removed from the ceiling in the mechanical room, leaving multiple open areas in the ceiling with visible debris and dust present. He stated that this was done around [Central Sterile's] schedule. I should have had them seal the holes as they removed each piece of apparatus [reserve tanks and pipes] from the ceiling. The work was scheduled to be completed but was pushed back due to staffing issues."

- On 4/24/2025 at 12:42, during an interview with the Director of Engineering/Maintenance, he was asked if he followed the HRH's Infection Control Policy: Construction and Renovations for this project. The Director of Engineering/Maintenance responded, "No, I did not work with Infection Control on this project because it was small."

2. Surgical Attire

The HRH "Surgical Attire" policy, last reviewed 1/10/2025, states in part, ... "Jewelry, including earrings, necklaces, watches, and braclets that cannot be contained or confined within the surgical attire should not be worn in restricted areas. Necklaces and earrings may be worn if totally concealed ... ."

On 4/23/2025, at approximately 12:42 PM, the Central Sterile Technician ("CST"), who was working in the Central Sterile Room ("CSR"), a restricted area, was observed wearing earrings that were not contained within her surgical attire. The surgical technician was asked if it was okay for her to wear earrings and she stated yes.

On 4/23/2025 between 8:00 PM and 9:30 PM, the CST and the Operating Room Registered Nurse, while working in the periOperative area, a restricted area, were observed wearing earrings that were not contained within their surgical attire.

Based on document reviews, interviews and interviews, the hospital failed to provide a sanitary environment including one (1) of one (1) chemical room in the dietary department, ceiling vent of one (1) of three (3) elevators, wooden handrails outside of two (2) of three (3), and torn covebase outside the elevator outside of one (1) of three (3) elevators.

Findings:

On 04/23/2025 and 04/24/2025, surveyors observed the following while walking through the facility:

On 04/23/2025 at 8:57 AM, the chemical room in the dietary department was observed.
- The wooden storage area containing cleaning chemicals had several gouges and chipped paint which could not be properly cleaned and sanitized.
- A work order to replace the wooden storage was placed on 01/24/2025.

On 04/24/2025 at 1:12 PM, an elevator was observed.
- The back lower panel was not intact, open, and sharp edges which could not be properly cleaned and sanitized

On 04/24/2025 from 1:13 PM to 1:18 PM, the wooden handrails outside of the two (2) elevators (one was out of service) were observed.
- There were several gouges in the wooden handrails which could not be properly cleaned and sanitized

On 04/24/2025 at 1:18 PM, the covebase outside of an elevator was observed.
- The corner piece of the covebase was not intact and could not be properly cleaned and sanitized.

On 04/24/2025 at 1:19 PM, the vent in the ceiling of the elevator was observed.
- The vent had a significant amount of dust build up.


On 04/24/2025 at approximately 1:30 PM, the Engineering/Maintenance Director was asked if the above items were part of a preventative maintenance program. He stated the following:
- No, it is not part of the program;
- These items would be caught by staff members who would then place a work order to repair; and
- We have a monthly surveillance committee that completes rounds in the hospital that would also identify items that need repair.

On 04/25/2025, the above items were not identified by the Surveillance Committee for the minutes reviewed for 09/2024, 10/2024, 11/2024, 01/2025, 02/2025 and 03/2025.

Based on document review, observation, and interviews, it was determined that the hospital was not incompliance with §485.613(b)(3) of the 42 Code of Federal Regulation part 489 Responsibilities of Medicare, in accordance with
§489.100, 489.102, and 489.104 of this chapter.

The hospital failed to ensure that two (2) out of five (5) patients were offered the necessary documents to execute an Advance Directive.

Findings:

Houlton Regional Hospital's policy titled, "Advance Directives," dated 06/23/2023, "If the patient has not executed an Advance Directive, information and forms necessary to execute an Advance Directive will be offered."

On 04/24/2025, at 9:15am and 9:20am, two (2) out of five (5) charts did not have documentation to support offeriing Advance Directive information to their patients who were admitted to the hospital. This was verified by the Patient Care Coordinator at that time.