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Based on observation, interview and document review, the critical access hospital (CAH) failed to ensure preventive maintenance had been performed on 5 of 17 patient beds. This included a bariatric patient bed that had been placed into service prior to it being inspected. In addition, the CAH failed to ensure preventative maintenance had been performed on two of two overhead surgical lights and bulbs.

Findings include:

On 8/8/16, at 1:30 p.m. a tour of the nursing unit was completed with registered nurse (RN)-C, the CAH's nurse manager. RN-C stated the CAH had received some used beds from Fargo and Bemidji a couple of months ago. RN-C confirmed it was the responsibility of the Bemidji maintenance department to conduct the preventive maintenance (PM) on all patient beds. RN-C stated the bariatric patient bed in room 109 was a brand new bed which had arrived a couple of months ago. RN-C verified this bariatric bed had no PM sticker on the bed which would have indicated the due date for the next PM. RN-C confirmed the PM sticker on bed numbered 1727, indicated the PM had been due on 2/2016, (six months past due for inspection) and the PM sticker on bed numbered 1749, indicated the PM had been due on 3/2016, (5 months past due for inspection).

On 8/8/16, at 2:44 p.m. safety/security manager (SSM) and plant maintenance supervisor (PMS) confirmed the patient beds should have a PM check completed annually. PMS confirmed the maintenance department was responsible for conducting the PM checks on the beds and to inspect any patient bed prior to the bed being placed into service. After each PM inspection a colored sticker should be placed on the bed which indicated the due date of the next PM. PMS stated he was unsure if the patient beds at the CAH had been checked as the maintenance department did not have them on their radar to check. SSM and PMS confirmed the bariatric bed lacked a PM sticker.

On 8/9/16, at 11:41 a.m. PMS confirmed the following patient beds were past due on their annual PM check:

- Bed 1727 PM due 2/2016 (6 months past due for inspection)
- Bed 520045 PM due 5/2016 (3 months past due for inspection)
- Bed 520063 PM due 3/2015 (18 months past due inspection)
- Bed 1749 PM due 3/2016 (5 months past due inspection)

In addition, PMS confirmed the bariatric bed had not been inspected prior to being placed into service. PMS was unsure of the date the bariatric bed had arrived.

On 8/10/16, at 9:15 a.m. during the tour of the operating room (OR), two overhead surgical lights were observed without PM sticker information. Registered nurse (RN)-G stated she was unsure of when they were last checked.

On 8/10/16, at 12:55 p.m. the director or nursing (DON) confirmed the overhead surgical lights and bulbs were not on the PM checklist and stated they were last checked in 2012.


On 8/11/16, at 10:45 a.m. the DON stated the surgical lights were hardwired in therefore, did not need PM checks. However, the DON was unsure if the light bulbs required PM checks to ensure proper functioning was maintained. When asked, the DON stated the CAH did not have the manufacturer's guidelines for the bulbs or lights.

Equipment policy dated 2/1/16, indicated preventive maintenance would be conducted on non-medical equipment as indicated on an ongoing basis.

The CAH's Bed Maintenance Procedure [undated] indicated all new patient beds would be inspected for electrical leakage to ground prior to being placed into service. The bed should be tagged with a PM due date one year from the initial inspection. In addition, all beds would be inspected annually.


28035

Based on observation, interview, and document review, the critical access hospital (CAH) failed to ensure 1 of 1 (Room 108) negative pressure room was properly maintained and monitored.

Findings include:

On 8/8/16, at 1:30 p.m. a tour of the nursing unit was completed with registered nurse (RN)-C the CAH's nurse manager. During the tour, patient room 108 was observed to have the capabilities of being converted to a negative pressure room (for airborne isolation - a room which had a ventilation system that generated a negative pressure to allow air to flow into the isolation room, while preventing contaminated air from escaping the isolation room). RN-C confirmed room 108 was the CAH's negative pressure room. RN-C demonstrated the negative pressure room was activated by closing the door and RN-C flipped two switches which were located across the hall in the housekeeping closet. RN-C was unaware of how often room 108 was checked to assure the negative pressure worked appropriately. RN-C confirmed the Bemidji maintenance department would be responsible for the routine maintenance of this room.

On 8/8/16, at 3:01 p.m. safety/security manager (SSM) and plant maintenance supervisor (PMS) acknowledged they were both unaware that patient room 108 could be utilized as a negative pressure room. SSM and PMS were unaware of how to activate the negative pressure ventilation system for room 108. PMS stated the ventilation system for the negative pressure room should be checked weekly by maintenance and then quarterly by an outside contractor. SSM and PMS confirmed they had no idea when the last time the negative pressure ventilation system in room 108 had been maintained or monitored as they had not had this on their radar to check. PMS verified the monitoring of this room should definitely be completed.

On 8/11/16, at 10:06 a.m. RN-C verified patient (P21) had been on airborne precautions from 3/11/16, until 3/13/16, and placed in the negative pressure room (room 108). The CAH lacked documentation that during this time the negative pressure ventilation system for room 108 had been monitored.

Airborne Infection Isolation Room policy dated 2/10/09, indicated patients with a highly infectious airborne illness would be placed in a negative pressure room. The negative pressure room would be monitored monthly unless there was a patient in the room then it would be monitored daily.

Based on interview, and document review, the critical access hospital (CAH) failed to ensure provisions were in place for emergency fuel availability in order to be able to continue to provide patient care without interruption in the event of an emergency.

Findings include:

On 8/8/16, at 2:00 p.m. during environmental tour with the safety and security manager (SSM) and the plant maintenance supervisor (PMS) a copy of the facility emergency fuel policy was requested for review.

On 8/10/16, at 4:30 p.m. a copy of an unsigned emergency fuel agreement between the facility and Cenex-Red Lake Coop was provided upon second request.

On 8/11/16, at 8:00 a.m. an emergency fuel agreement between the facility and Cenex-Red Lake Coop was signed 8/11/16.

On 8/11/16, at 9:51 a.m. the PMS stated he was not aware of any written agreement between the facility and Cenex for emergency propane. He stated he felt they had a verbal understanding with Cenex and stated he felt they would always be able to provide them with emergency propane as they were a 24 hour a day, 7 day a week operation.

On 8/11/16, at 2:30 p.m. Support Services Supervisor confirmed the facility used only propane as their fuel source and confirmed the facility did not have a signed agreement in place for emergency propane until today.

Review of the Sanford Bagley Medical Center Emergency Operations Plan dated 11/15, identified non-medical supplies including fuel would be replenished as able by normal vendors. The plan further identified if normal vendors were unable to replenish supplies, local vendors will be contacted for possible assistance.

Review of the facility Emergency Management Plan dated 12/15, identified the goal of the emergency management plan was to assure safety and well-being of patients, visitors and staff during an emergency situation effectively preparing for and managing an incident and restoring the facility to the same operational capabilities as pre-emergency levels.

Based on observation, interview, and document review the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to Life Safety Code inspection tags: K18, K29, K50, K62, K144, K147

Based on interview and document review, the critical access hospital (CAH) was not in compliance with 485.627 Condition of Participation for Organizational Structure due to the failure of the governing body to assure full legal responsibility for the implementing and monitoring policies and bylaws governing the CAH's total operation.

Findings include:

See C241: The governing body failed to assume full legal responsibility for the implementation of medical staff and governing body by-laws related to the appointment/reappointment of medical staff to ensure patients received quality care. The governing body failed to ensure medical staff bylaws were current and operationalized. In addition, the governing body failed to ensure active involvement with the day to day activities of the CAH.

Based on interview and document review, the critical access hospital (CAH) failed to ensure 7 of 13 medical staff (NP-A, NP-B, MD-B, MD-C, MD-E, PA-A, CRNA-A) had been reappointed according to CAH policy and the medical staff by-laws. The CAH's medical staff by-laws were outdated and some portions obsolete. In addition, the CAH's advisory board activity was not consistently provided to the Sanford Health of Northern Minnesota Board. This had the potential to affect all patients served by the CAH.

Findings include:

CREDENTIALING

On 8/11/16, at 9:23 a.m. the credentialing files were reviewed with medical staff service manager (MSSM), medical staff coordinator (MSC), administrative director (AD), and the vice president of operations (VPO). The findings of this review included:
1. Nurse practitioner (NP)-A's credentialing file indicated NP-A had submitted an application for the reappointment of privileges at the CAH on 1/13/15. The CAH's medical staff recommended NP-A's approval at the 8/17/15, medical staff meeting. The governing board approved NP-A's reappointment on 9/3/15 (233 days from reappointment request until governing board approval). NP-A's file lacked documentation of when NP-A's prior reappointment had expired to determine if NP-A's privileges had expired since the reappointment process initiated on 1/13/15, and the time to governing board approval (9/3/15), exceeded 180 days.
On 8/11/16, at 12:46 p.m. MSSM confirmed the CAH was unable to locate NP-A's immediate prior privilege form. The CAH was unable to confirm if NP-A's privileges had expired or not during the credentialing process (initiated on 1/13/15) which exceeded the 180 days.
2. Review of NP-B's credentialing file indicated NP-B had submitted an application for the reappointment of privileges at the CAH on 1/5/15. The CAH's medical staff recommended NP-B's approval at the 8/17/15, medical staff meeting. The governing board approved NP-B's reappointment on 9/3/15 (241 days from reappointment request until governing board approval). NP-B's file lacked documentation of when NP-B's prior reappointment had expired to determine if NP-B's privileges had expired since the reappointment process initiated on 1/5/15, and the time to governing board approval (9/3/15), which exceeded 180 days.
On 8/11/16, at 9:46 a.m. MSSM confirmed the time from when a medical staff member requested privileges until the time when the governing board provided approval should not exceed 180 days.
On 8/11/16, at 12:46 p.m. MSSM confirmed the CAH was unable to locate NP-B's immediate prior privilege form. The CAH was unable to confirm if NP-B's privileges had expired or not during the credentialing process (initiated on 1/5/15) which exceeded the 180 days.
3. Medical doctor (MD)-B's credentialing file indicated MD-B had submitted an application for reappointment at the CAH on 2/3/14. MD-B's reappointment application lacked identification of what privileges MD-B had requested. MD-B's file lacked documentation that the CAH's medical staff had recommended MD-B's reappointment to the CAH. The governing body had approved this reappointment on 10/1/14, without information related to which privileges were being requested by MD-B to perform at the CAH. In addition, there was no information available related to knowledge and performance for the governing board to base a reappointment.
On 8/11/16, at 9:55 a.m. MSC confirmed MD-B's 2/3/14, reappointment application for the CAH lacked a delineation of privileges. In addition, MD-B's application lacked a response to the question if MD-B had requested new privileges. AD confirmed MD-B had performed surgical procedures at the CAH over the past couple of years.
On 8/11/16, at 1:56 p.m. the AD confirmed no peer review or review of quality had been conducted on MD-B in the past couple of years. The AD stated since MD-B performed similar cases at the hospital in Bemidji and if MD-B was okay to practice there; their thought was that MD-B would be okay to practice at the CAH.
4. MD-C's credentialing file lacked any appointment/reappointment application for privileges at the CAH.
On 8/11/16, at 10:05 a.m. MSC confirmed MD-C's file lacked an appointment/reappointment application for privileges at the CAH. The AD confirmed MD-C was the active medical director of the CAH's laboratory.
On 8/11/16, at 1:52 p.m. the AD stated any medical director at the CAH should be credentialed at the CAH.
5. MD-E's credentialing file lacked any appointment/reappointment application for privileges at the CAH.
On 8/11/16, at 10:45 a.m. MSSM confirmed MD-E provided teleradiology services at the CAH, but MD-E's privilege form for teleradiology had not been signed. Thus, MD-E had not been credentialed to provide services at the CAH.
6. Physician assistant (PA)-A's credentialing file indicated PA-A had submitted an application for reappointment at the CAH on 3/2/15. The governing board approved PA-A's application on 8/6/15. The CAH's medical staff recommended PA-A's approval to the governing board on 8/17/15, as indicated in the 8/17/15, medical staff meeting minutes. The governing board approved PA-A's application for reappointment, prior to having received the medical staff recommendation for reappointment.
7. Certified registered nurse anesthetist (CRNA)-A's credentialing file indicated CRNA-A had submitted an application for reappointment at the CAH on 9/24/14. The governing board approved CRNA-A's application on 10/31/14. The CAH's medical staff recommended CRNA-A's approval to the governing board on 1/19/15, as indicated in the 1/19/15, medical staff meeting minutes. The governing board approved CRNA-A's application for reappointment, prior to having received the medical staff recommendation for reappointment.

Medical Staff By-Laws of Clearwater County Memorial Hospital dated 7/14/1994, indicated that at the time of medical staff appointment/reappointment an application for privileges would be submitted, and the application would be acted upon by the board of trustees (of Clearwater County Memorial Hospital) as recommended by the medical staff.

Clearwater Health Services - Licensure of Appropriate Personnel policy dated 2/2009, indicated all recredentialing or licensing of hospital medical personnel would be brought to the medical staff for review, recommendations and approval. These recommendations would be documented in the medical staff minutes. The chief executive officer would then bring the minutes and the list of these credentials to the following board meeting for board review and approval. These would also be documented in the board minutes.

Establishing Telemedicine Services Between Sanford Facilities - Enterprise policy dated 4/25/16, indicated providers must be credentialed and granted privileges to perform telemedicine services at the originating-site medical center (site in which the patient receiving telemedicine services was located) and were subject to the credentialing and privileging process at the originating site.

BYLAWS

Medical Staff By-Laws of Clearwater County Memorial Hospital dated 7/14/1994, and Clearwater County Memorial Hospital Rules and Regulations of the Medical Staff dated 1991, were reviewed with the AD on 8/10/16, at 1:37 p.m. The AD confirmed these were the most current medical staff bylaws and rules and regulations for the CAH. The AD stated the current bylaws dated 1994, and rules and regulations dated 1991, should be followed by the CAH. The AD confirmed some of the parts of the bylaws and rules and regulations were outdated. The AD confirmed the following review and findings:

- The document referred to the CAH as "Clearwater County Memorial Hospital" (CCMH). The CAH's name changed to Sanford Bagley Medical Center in 2/2012.
- A Board of Trustees no longer existed at the CAH. The CAH now functioned with an Advisory Board.
- In Section 2 and 3 related to application of privileges and terms of appointments of the medical staff. The medical staff no longer provided the Board of Trustees (past CCMH Board) with their application for privileges as recommended by the CAH medical staff. Nor does the CCMH or the current advisory board of the CAH appoint members of the CAH's medical staff. The appointments are made by the Sanford Health of Northern Minnesota board.
- Under the divisions of the medical staff - section 2 and 4 indicated the consulting staff would provide services with no charge in the care of free patients if requested by a member of the attending or associate medical staff. In addition, in section 4- a duty of the active staff included providing free charity care patients on a rotational basis. Although the CAH had a process for providing charity care, this was no longer how that process functioned.
- Under article Y1 - OFFICES AND COMMITTEES - section 2 - committees. The following committee's outlined in the bylaws no longer existed at the CAH: an executive committee, medical records, utilization review or infection control committee.
- Under section XV. AMENDMENTS related to the process for amendment or repeal of the bylaws. The bylaws indicated amendments to the bylaws would be recommended by the medical staff and would not be in forced or effect until passed by the CCMH board. The CCMH board of trustees no longer existed so this process would be different.
CCMH Rules and Regulations of the Medical Staff review with AD included:
- Under #3 - The reference to a utilization review (UR) committee was inaccurate as the CAH no longer had a UR committee.
- Under #6 - related to charity care cases. The process had changed for caring for charity care cases.
- Under #7 - related to all orders for treatment should be in writing. The CAH had an electronic record which the medical staff now entered their orders for treatment electronically.
- Under #19 - related to a transfer form for patient handoffs. This form and process no longer existed.
- Under #20 - related to emergency room weekend coverage. The CAH's emergency room was covered by primarily mid-levels with medical staff backup.

In addition, the AD verified the CAH received telemedicine services specifically in the CAH's emergency room and the current medical staff bylaws and rules and regulations lacked reference to telemedicine services including the credentialing process for telemedicine medical staff.

CAH'S ADVISORY BOARD

The CAH's organizational chart provided upon entrance on 8/8/16, lacked any reference to a board. The AD was listed at the top of the organizational chart.

The CAH's organizational chart dated 8/10/16, indicated the AD reported to the vice president of operations Bemidji market, who reported to the executive vice president Bemidji Market, who reported to the Sanford Health of Northern Minnesota Board of Directors. This organizational chart dated 8/10/16, lacked reference to the Sanford Bagley Advisory Board (SBAB).

On 8/9/16, at 1:34 p.m. the AD confirmed the SBAB met on a quarterly basis. Representatives from the Sanford Bemidji leadership (vice president of operations - VCO and vice president of finance- VCF) attended the SBAB meetings and the VCO was responsible for providing the Sanford Health of Northern (SHNM) board an update from the CAH. The AD confirmed no member of the SBAB attended or was a member of the SHNM board.

On 8/10/16, at 2:06 p.m. the AD verified the SBAB had no power to make decisions regarding the CAH, they could only make recommendations or advise the SHNM board. The AD confirmed the minutes of the SBAB for 8/21/15, 11/11/15, 1/29/16, and 4/29/16, reflected meetings where information had been shared and no recommendations made by SBAB. The AD verified the SBAB had no part in the credentialing of the medical staff who provided services at the CAH. The AD confirmed the SBAB were not provided the CAH's medical staff meeting minutes. The AD stated the SBAB members felt very strongly about the healthcare at the CAH.

On 8/11/16, at 1:55 p.m. the AD confirmed the SBAB was not an "operational" board. The AD verified that even though the SBAB bylaws dated 2014, indicated one of the SBAB's duties was to advise on quality and quantity of services provided; the SBAB had not received medical staff meeting minutes nor any quality committee meeting minutes for their review. The AD confirmed the CAH's performance improvement (PI) plan had been provided to the SBAB at their 11/11/15, meeting. However, the 11/11/15, SBAB meeting minutes lacked reflection if the SBAB recommended/advised the PI plan to be approved.

The Bylaws of the Sanford Bagley Advisory Board dated 2014, indicated the SBAB had been established to advise the SHNM board of directors regarding matters which pertained to the operations of the CAH. Under SECTION III - Duties of the SBAB included (not an inclusive list):
- To advise on quality and quantity of services provided.
- To participate in annual strategic planning sessions of the hospital.

The SBAB meeting minutes dated 8/21/15, indicated the AD provided an update which included that the Sanford Bagley leadership were in the early development of a strategic plan to see what the future of Bagley looked like. The SBAB minutes lacked documentation of involvement of the SBAB with this strategic planning process.

The SHNM board of directors meeting minutes dated 10/1/15, indicated the SHNM had received and approved the SBAB meeting minutes dated 8/21/15.

The SBAB meeting minutes dated 11/11/15, indicated AD provided the board with the 2016 PI Plan for review. The SBAB minutes lacked documentation whether the SBAB recommended/advised approval of the 2016 PI plan or recommended/advised and changes to the PI plan.

The SHNM board of directors meeting minutes dated 2/4/16, lacked review/approval of the 11/11/15, SBAB meeting. However, included discussion related to the approval of a capital improvement grant applied for by the CAH.

The SBAB meeting minutes dated 1/29/16, indicated AD the Sanford Health Bagley Strategic Plan 2016 had been reviewed and presented. The SBAB minutes lacked documentation whether the SBAB recommended/advised the approval of the strategic plan.

The SHNM board of directors meeting minutes dated 3/3/16, lacked review/approval of the 1/29/16, SBAB meeting. However, included reference to the capital improvement grant for the CAH.

The SBAB meeting minutes dated 4/29/16, indicated booklets had been provided which detailed the CAH's plan of action for addressing community needs. The SBAB minutes lacked documentation of SBAB's involvement with the community needs assessment or if the SBAB recommended/advised the approval of this action plan.

The SHNM board of directors meeting minutes dated 5/5/16, referenced the community health needs assessment conducted for Bemidji and Bagley. In addition, AD provided an update on the CAH regarding the nursing contract and capital improvement grant.

The SHNM board of directors meeting minutes dated 6/16/16, lacked review/approval of the 4/29/16, SBAB meeting. The minutes referenced Bagley Medical Center and Clinics in the board PI committee roles and responsibilities. In addition, a Leadership Report included an update from the AD which made note of a recent OSHA (Occupational Safety and Health Administration) survey conducted on 4/27/16.

The SHNM board minutes for the dates noted above included the CAH's medical staff meeting minutes and recommendation for approval for appointment and reappointment of the CAH's medical staff.

Based on interview and document review, the critical access hospital (CAH) failed to inquire if 6 of 20 patients (P8, P15, P22, P23, P24, P25) had a current advance directive or wanted information on advance directives. In addition, the emergency department (ED) lacked having advance directive information readily available.

Findings include:

P8 was admitted to the CAH on 12/2/15. P8's medical record indicated P8 did not have a "Living Will" on file at the CAH. In addition, P8's medical record lacked documentation that advance directive information had been offered to P8.

P15 was admitted to the CAH on 11/2/15. P15's medical record indicated P15 did not have a "Living Will" on file at the CAH. In addition, P15's medical record lacked documentation that advance directive information had been offered to P15.

On 8/9/16, at 11:00 a.m. health information management (HIM) supervisor confirmed P8 and P15's medical record lacked documentation that P8 and P15 had been asked if they had a current advance directive and if they had received information on advance directivesP22 was admitted to the CAH on 6/10/16, for an outpatient surgical procedure. P22's medical record indicated P22 did not have a "Living Will" on file at the CAH. In addition, P22's medical record lacked documentation that advance directive information had been offered to P22.

P23 was admitted to the CAH on 10/21/15, for an outpatient surgical procedure. P23's medical record indicated P23 did not have a "Living Will" on file at the CAH. In addition, P23's medical record lacked documentation that advance directive information had been offered to P23.

P24 was admitted to the CAH on 10/21/15, and 3/25/16, for outpatient surgical procedures. P24's medical record indicated P24 did not have a "Living Will" on file at the CAH. In addition, P24's medical record lacked documentation that advance directive information had been offered to P24 during both of the hospital admissions.

P25 was admitted to the CAH on 1/22/16, for an outpatient surgical procedure. P25's s medical record indicated P25 did not have a "Living Will" on file at the CAH. In addition, P25's medical record lacked documentation that advance directive information had been offered to P25.

On 8/11/16, at 9:45 a.m. nurse practitioner (NP)-C verified there was no signage or advance directive information available or posted in the emergency department (ED) and stated there should be.

On 8/11/16, at approximately 11:00 a.m. the director of nursing verified the aforementioned medical records lacked advance directives and documentation indicating advance directive information had been provided. The DON stated each patient, including outpatients, were to be questioned regarding the existence of an advance directive and/or offered information regarding advance directives.

On 8/11/16, at 2:12 p.m. NP-C confirmed the ED patient information packet did not contain advance directive information therefore, all ED patients would not be asked about advance directives. NP-C stated when a patient was admitted to the CAH they would receive advance directive information in the admission packets.

On 8/11/16, at 3:25 p.m. the DON stated she was unaware the ED did not have signage for advance directives and that patients were not talked with about advance directives until admission to the CAH and agreed this should be discussed prior to admission.

The Advance Directives policy and procedure revised on 8/15, indicated all adult patients or their representatives would be asked about the existence of an advance directive and any individual interested in completing an advance directive would be provided information and assistance.

Based on interview and document review, the critical access hospital (CAH) failed to ensure policies of the CAH were reviewed annually as directed by CAH policy. This had the potential to affect all patients who received care at the CAH.

Findings include:

On 8/10/16, at 9:56 a.m. registered nurse (RN)-C, CAH nurse manager, stated the CAH recognized they had a huge gap with getting policies up to date and reviewed. RN-C confirmed CAH policies should be reviewed annually. RN-C stated there was not a policy review committee at the CAH. RN-C stated each department was responsible for the development, review, and revision of their policies. RN-C stated all patient care policies were brought to the medical staff meetings for their review and approval.

On 8/11/16, at 8:27 a.m. the administrative director (AD) stated approximately 15% of the CAH policies were up-to-date.

On 8/11/16, at 1:46 p.m. the AD verified the majority of infection control policies for the CAH were beyond their annual review date.

Review of the CQI meeting minutes from 8/25/15, through 7/7/16, lacked mention of an annual review of CAH policies.

Policies and Procedures, Review, Retention and Format policy dated 2/2009, indicated each departmental supervisor was responsible for the annual review of policies. In addition, all patient care policies were reviewed annually by a group of professionals that included one or more physicians and one or more mid-level practitioners. The policy/procedure annual review would be documented within the minutes of the annual meeting of the quality meeting.

Based on observation, interview and document review, the critical access hospital (CAH) failed to establish a facility-wide effective infection control surveillance program. This had the potential to affect all patients who received care at the CAH.

Findings include:

Review of the CAH's infection control program indicated a system which lacked a comprehensive, concurrent, surveillance program with ongoing analysis and interpretation of infections and infection risk. The most current infection control logs were reviewed and indicated the following (the CAH lacked infection control logs for the months of July and August):

- June Infections (dated 7/20/16) included a line listing of one urinary tract infection; two tick borne infections; two acute febrile illnesses; two pyelonephritis; one pneumonia and one lower respiratory tract infection. The report indicated no hospital acquired infections. The June 2016, infection control log/report lacked any additional information.
- January 2016 - May 2016, logs included a categorization of infection which indicated the number of infections for each site of infection such as integumentary (skin), respiratory, urinary, gastrointestinal, bacteremia, and other. In addition, the data collected included patient identification number, service (inpatient or observation), date of admission, infection on admit, hospital acquired, onset of infection, diagnosis, was a culture obtained, date of the culture, and organism isolated.

The infection control reports for 1/2016, through 6/2016, lacked measures selected for monitoring, overall analysis of trends, interventions to address any issues identified and then monitoring of the effectiveness of the interventions through further data collection and analysis. In addition, the infection control logs lacked information regarding antibiotic treatment received and antibiotic regime reviewed for appropriateness.

On 8/10/16, at 9:02 a.m. registered nurse (RN)-C confirmed she oversaw the infection control program. RN-C stated she had had no additional or special training in infection control. RN-C had delegated the data collection task to RN-E. RN-E was allotted 12-24 hours a month for infection control. RN-E conducted a chart review of inpatients; placed this information on the infection control logs and provided the information to RN-C. RN-C stated the CAH lacked a process to alert RN-E of any cultures taken or resulted, instead RN-E would run a report with this information as she conducted the chart reviews. RN-C confirmed the CAH lacked an infection control committee however, the infection control logs were presented at the monthly quality committee meeting. RN-C verified the June infection control log was the new reporting system for infections that the CAH had adopted. RN-C confirmed the infection control logs lacked information regarding antibiotic regime or review and information to assist with identifying cross contamination. In addition, RN-C confirmed the only analysis of infections was the categorization of infections. RN-C verified the CAH had not included the emergency department or outpatient areas in the CAH's infection control surveillance program, nor were these areas assessed for the need to conduct surveillance. RN-C stated someone from surgery was collecting surgical site infection rates, however, RN-C was unsure of how that information was reported. RN-C verified the CAH lacked a process to correlate employee illnesses with patient infections as all employee illness information went to Bemidji. RN-C verified the CAH had not conducted any surveillance audits such as compliance with hand hygiene. RN-C stated the CAH's infection control program was still being developed and had not formally or informally been evaluated.

On 8/11/16, at 1:46 p.m. the administrative director (AD) confirmed RN-E was not available for interview. In addition, the AD verified the majority of infection control policies for the CAH were beyond their annual review date.

Infection Control Screening and Log policy dated 5/2007, indicated all infections occurring during hospitalization shall be investigated and reported. The patient's infection control screening was completed during the patient's stay by the nursing staff or the infection control coordinator, which included assessment of infection on admission, cultures and reports, procedures and treatments. In investigating infections, the infection control coordinator checked each case to determine if it was an isolated case or not.

Infection Control Guidelines policy dated 12/2008, indicated surveillance and control of nosocomial infections would be the responsibility of the infection control committee. A system for reporting, evaluating and analyzing nosocomial infections would be the responsibility of the infection control coordinator. Post-discharge infection surveillance would be accomplished on all patients who were at high risk for acquiring an infection.

Based on interview and document review, the critical access hospital (CAH) failed to designate a qualified individual responsible for dietary services to ensure the nutritional needs of inpatients were met, and also failed to develop a process to identify those patients at nutritional risk. This had the potential to affect all patients who received nutritional services at the CAH.

Findings include:

On 8/10/16, at 1:45 p.m. RN-C, the CAH's nurse manager confirmed the Support Services Supervisor (SSS) was responsible for dietary operations. RN-C stated she was not sure of the SSS position requirements or his background or training. She stated nurses determined if patients were at nutritional risk and either consulted the registered dietitian (RD) or the Food Services Manager from Bemidji for clinical reference as needed.

On 8/10/16, at 2:00 p.m. registered nurse ( RN-I) stated there were nutrition screening questions in the electronic medical record nursing answered, and stated patients were not identified at nutrition risk. RN-I stated if she felt the patient required a nutrition consult she would verbally asked the provider or enter comments in that screen of the computer. RN-C stated she was unsure of how much they referred patients to the registered dietitian (RD) from Bemidji, or if patients had been discharged before they were assessed by the RD. She stated she was unaware if the RD was notified of each admission. RN-C confirmed the nutritional screen data information completed by the nurse did not identify or alert RD or physician if a patient was at nutritional risk based on the screening questions.

On 8/11/16, at 9:57 a.m. SSS stated he supervised dietary services. He stated he would contact the food services manager for help, and stated he did not contact her that much. He stated he was going to have dietary training but it had not been set up yet. He also stated he had not worked with the RD yet. He stated the Dr's would determine if a patient required a nutrition consult. He stated he was not sure how often the RD was consulted or if consults were completed before discharge. He stated he was sure the physician notified the RD of admissions. He stated he was unaware of patient admissions or how to monitor for lapses in the process. He stated he had never worked in dietary before and had no dietary supervisory experience.

On 8/11/16, at 2:25 p.m. the executive director (ED) confirmed the facility did not have a policy or procedure in place for identifying patients at nutritional risk.

On 8/11/16, at 3:30 p.m. during follow-up interview RN-C confirmed they did not have a process in place for identifying patients at nutrition risk. She stated she relied on the providers for nutrition screening and contacting the RD. She stated the facility relied on Bemidji for clinical nutrition services. She stated she thought there was an agreement with Bemidji for clinical nutrition services but wasn't aware of the agreement terms.

Review of the SSS job description dated 2/6/16, identified he was to ensure all aspects of food production are complaint with regulations, required a bachelor's degree in business or health related field, and had a first class boiler's license. The job description did not identify his role in the provision of clinical nutrition services.

Review of the RD's job description dated 9/21/14, identified the RD would identify patients at nutrition risk.

Review of the Food Services Scope of Practice policy, dated 12/15 identified food service maintained a continuous interaction with nursing expressing concerns for a patient's special needs as necessary and a RD from Bemidji may be contacted to provide additional support, education, or recommendations to patients/family/staff with nutrition concerns.

Based on interview and document review, the critical access hospital (CAH) failed to ensure a comprehensive list of services furnished under agreement or arrangement had been maintained. This had the potential to affect all patients who received services at the CAH.

Findings include:

On 8/9/16, at 12:00 p.m. the administrative director (AD) provided the CAH's current list of services provided through agreements or arrangements. The CAH's Contracted Services list [undated] identified 12 company names and the services they provided.

On 8/10/16, at 1:30 p.m. the AD confirmed the contract list provided was not an inclusive list. The AD verified some of the agreements or contracted services missing from the list were: NEI Bottling (emergency water supplier), Solway Fire Department (non-potable emergency water supplier), Speech Therapy service agreement with Sanford Bemidji Medical Center, GE Healthcare (biomedical services), Clean Harbors Environmental Services (hazardous waste disposal agreement), Mobile Ultrasound Services with Sanford Medical Center Fargo, and Central Minnesota Diagnostic Inc. (computerized tomography services). In addition, the CAH's contracted services list lacked information regarding whether the services were offered on or off site; whether there was any limit on the volume or frequency of the services provided; and when the services were available.

Based on interview and document review, the critical access hospital (CAH) failed to ensure an individualized, comprehensive care plan had been developed to meet each patient's assessed needs for 9 of 20 inpatients (P12, P13, P14, P15, P16, P17, P18, P19, P20) whose records were reviewed.

Findings include:

P12 was admitted to the CAH on 7/4/16, with diagnoses which included altered mental status, hypoglycemia (low blood sugar), diabetes, chronic kidney disease and anemia related to chronic rectal bleeding.
P17 was admitted to the CAH on 1/16/16, following a cerebrovascular accident (stroke) due to thrombosis (a blood clot formed inside one of the brains arteries and the clot blocked blood flow to a part of the brain). P17 was placed on supportive care.
P18 was admitted to the CAH on 1/9/16, for pneumonia and had a history of diabetes.
P19 was admitted to the CAH on 6/23/16, for congestive heart failure (decrease in heart function to pump blood), lower respiratory tract infection (which was treated with intravenous antibiotics), weakness and atrial fibrillation (irregular heart rate).
P13 was admitted to the CAH on 3/29/16, with diagnoses which included urinary tract infection, deconditioning and mental status change.
P14 was admitted to the CAH on 4/30/16, with cardiac syncope (fainting) and congestive heart failure.
P15 was admitted to the CAH on 8/14/15, with mastoiditis (infection of jaw bone).
P16 was admitted to the CAH on 4/4/16, with pneumonia.
P20 was admitted to the CAH on 3/29/16, with pneumonia.

On 8/9/16, at 11:00 a.m. health information management (HIM) supervisor confirmed the above noted care plans for P12, P17, P18 and P19 were not comprehensive with regards to these patient's identified needs and diagnoses.

On 8/11/16, at 2:31 p.m. registered nurse (RN)-C, the CAH's nurse manager confirmed the following:
- P12's care plan lacked problem areas, goals and interventions related to diabetes care, hypoglycemic episodes, chronic kidney disease and mental status changes.
- P17's care plan lacked a problem area, goals and interventions related to neurological deficit and end of life care.
- P18's care plan lacked a problem area, goals and interventions related to impaired gas exchange, diabetes care, and infection.
- P19's care plan lacked a problem area, goals and interventions related to infection, impaired gas exchange, heart failure and cardiac concerns.
On 8/11/16, at 2:51 p.m. RN-C, the CAH's nurse manager stated she would expect nursing staff to develop a care plan for risks and pain and care plan interventions directly related to what the patient was admitted to the CAH for and confirmed the following:
- P13's care plan lacked problem areas, goals and interventions related to infection and cognitive function.
- P14's care plan lacked problem areas, goals and interventions related to falls and hyperkalemia (low potassium).
- P15's care plan lacked problem areas, goals and interventions related to infection.
- P16's care plan lacked problem areas, goals and interventions related to infection.
- P20's care plan lacked problem areas, goals and interventions related to infection.

The Patient Care Plans policy dated 12/2008, indicated all acute care and swing bed care patients would have an updated care plan based on the patient's diagnoses and changes in condition.

Based on observation, interview and document review, the critical access hospital (CAH) failed to ensure facility medical records were protected from water and fire damage.

Findings include:

On 8/10/16, at 9:55 a.m. during initial tour of medical storage areas health information management systems (HIMS) supervisor and HIMS clerk were unable to access the old clinic basement room which contained historical patient death records. The HIMS Clerk tried every key on her ring and stated no one had been in the room for years. The HIMS Clerk stated she would look for a key for the room and tour after she located the key.

On 8/11/16, at 10:45 a.m. during a follow up tour the HIMS Supervisor and Support Services Supervisor (SSS) accessed the room which contained historical patient death records. The room measured approximately 30' X 20'. There were no sprinkler heads above the records and water stained concrete on the floor in front of one of the chart racks. Both the HIMS Supervisor and SSS confirmed the records were not protected from fire or water damage.
The room which contained the active patient volume charts measured approximately 14' X 12'. The active patient volume records room contained additional patient medical record documentation from previous charts. There were no sprinkler heads observed to protect the records from fire and and no protection from water damage. There was 1 window above the records that was filled with brown leaves. Both the HIMS Supervisor and SSS confirmed these records were not protected from fire or water damage and stated they should be moved. The HIMS Supervisor stated he was not aware that patient medical records were stored in these areas and stated they should be moved for protection.
Review of the facility Record Retention and Destruction policy, dated 7/12/16, identified off-site storage facilities safeguard records from hazards including fire and water.

Based on observation, interview and document review, the critical access hospital (CAH) was found not to be in compliance with the Condition of Participation of Surgical Services 485.639 due to failure to ensure sterile surgical instruments, equipment and supplies were stored in a moisture controlled environment to ensure sterility, and failed to ensure the surgeon was granted privileges to perform procedures conducted at the CAH. In addition, the CAH failed to ensure the surgical department was supervised by an experienced staff member. This had the potential to affect all patients who received services in the surgical department.


Findings include:


On 8/10/16, at approximately 8:30 a.m. during the tour of the surgical department with operating central processing technician/operating room (OR) room assistant (ORA) revealed the current humidity of the OR/instrument/supply rooms was recorded at 67.9%. ORA stated the OR/central supply storage area and surgical suite humidity levels should be maintained between 20% and 60%. ORA stated if the humidity level was over 70%, staff were to check the sterile OR surgical instruments/supplies and equipment for compromised sterilization, however, confirmed these checks were not documented. ORA stated surgical/medical procedures were performed at the CAH every Friday. The ORA also stated the director of nursing (DON) was the surgical department's supervisor and she was unaware of where the surgeon's list of surgical privileges was posted. ORA stated the surgeon performed procedures such as hernia repair, gallbladder removal, vasectomies, carpal tunnel, and numerous colonoscopies.


The "Daily CPC Checklist" humidity level daily documentation monitoring form was reviewed with the ORA who confirmed the findings. The checklist indicated the OR humidity which also included the supply room levels were to be maintained between 20% and 60%. The checklist documentation for March, April and May 2016, indicated acceptable humidity levels. The June, July and August 2016, documentation revealed the following:

--June 2016, six of 30 days humidity levels ranged from 67% to 85%. The corrective action section of the form indicated the high humidity levels were reported to maintenance staff on 6/15/16, and 6/18/16. On 6/18/16, the note indicated air conditioning was down to 65 degrees with 66% humidity after air conditioning turned on.

--July 2016, 22 of 31 days the humidity levels ranged from 61%-74%. The corrective action section indicated on 7/3/16 and 7/4/16, the humidity levels were frequently monitored. On 7/4/16, a note indicated maintenance would be notified. A hand written entry dated 7/26/16, indicated humidity levels reported to maintenance, "stated unable to fix at this time." The OR Log revealed other than two colonoscopies, no surgical procedures had been scheduled on the days the humidity levels were not in appropriate parameters.

--August 2016, seven of 10 days the humidity level ranged from 64%-70%. The corrective action section indicated on 8/1/16, the humidity level was reported to maintenance staff. The OR Log revealed five colonscopies were performed and no surgical procedures had been performed.

The Charge Summary by Provider form from 1/1/14, through 7/31/16, revealed medical doctor (MD)-B had performed procedures such as excisions of abscesses/skin lesions/tumors, upper endoscopies, esophagogastroduodenoscopies (EGD: endoscopic procedure that visualizes the upper part of the gastrointestinal tract up to the duodenum), sigmoidoscopies, colonscopies, hemorrhoidectomies, laparoscopic cholecystectomy (removal of gallbladder), inguinal hernia repairs, umbilical hernia repairs, vasectomies, and carpal tunnels.

On 8/10/16, at 9:15 a.m. registered nurse (RN)-G stated the DON was the surgical department's supervisor. She stated MD-B performed surgical procedures at the CAH 2-3 days per month. RN-G stated MD-B's surgical privileges were not posted in the OR and she would ask the DON for MD-B's privileges, if needed.


On 8/10/16, at 11:15 a.m. the DON stated she had started as the OR/surgical department supervisor in March 2016, and had no surgical experience or specialized surgical education. The DON stated the CAH had an agreement with Sanford Health of Bemidji to provide supervision of the CAH's surgical department. The DON also stated if humidity was not in acceptable parameter, surgery would be canceled. During this interview, the CAH's support services supervisor in charge of the CAH's maintenance department stated he was made aware of the high humidity levels in July at which time the air handlers were "tweaked." He also stated the air handling system was functioning at it's maximum capacity and staff were to monitor the levels and if over 70% staff were to monitor the packaged surgical supplies and equipment to ensure no condensation was present and sterility was maintained. In addition, the DON stated she was unsure if monthly documentation of sterile supply and equipment checks were in place and plans to monitor for trending of compromised equipment and supplies, however, would need to involve the experts. The DON also stated she was unaware if MD-B's surgical privileges were posted or not. The DON stated there was no job description for the surgical department's supervisor or listed required qualifications for the position.


The Sanford Health surgical agreement form signed by the CAH's administrator on 6/15/16, indicated the ultimate responsibility for the CAH's surgical oversight would be the director of perioperative services (DOPS) at Sanford Bemidji Medical Center, or designee. Surgical oversight was defined and understood as the guidance and direction regarding policies and procedures, equipment needs and developing surgical services. Surgery and staff supervision would continue to be the responsibility of the CAH's nursing manager.


On 8/10/16, at 1:05 p.m. the administrator verified the DON was the designated supervisor of the surgical department and had no surgical experience or surgical education. She stated surgical/medical procedures were performed at the CAH weekly. She stated the surgical departments staff were directed to go to the DON with any questions, and if the DON was unable to answer them, she would call the DOPS at Sanford Bemidji Medical Center for direction. In addition, the administrator verified the CAH did not have an surgical department supervisor job description nor educational requirements for the position.


On 8/11/16, at 9:45 a.m. the plant operation supervisor (POS) who overseen both the Bagley CAH and Bemidji hospital maintenance departments confirmed he was aware of the ongoing high humidity levels. The POS stated the CAH's current air system was functioning at it's maximum capacity and the CAH would need to overhaul the entire HVAC system in order to improve functioning. The POS confirmed there was no current repair work or corrective action plan in place to fix the system and stated as of today, the CAH was looking at redesigning the HVAC system in order to improve functioning and maintain appropriate humidity levels.


On 8/11/16, at 10:00 a.m. the Sanford Bemidji director of perioperative services (DOPS) stated even though she was not employed at the CAH, she had become the CAH's surgical department supervisor "last week." She stated her first and only day at the CAH was 8/5/16, at which time she started reviewing the CAH's policies and procedures because a "majority" of the approximate 40 policies pertaining to the department were "expired." The DOPS also stated she "believed" the surgical department's staff were performing to standards. When she was done reviewing and approving the surgical department's policies and procedures, she would educate the staff on any new policies and procedures to ensure all surgical department's staff were performing according to the standards of care. The DOPS stated the CAH's DON was responsible to "oversee" the surgical department when she was not onsite at the CAH. The DOPS stated she was unsure how often she was going to be onsite at the CAH but was available by phone and would travel to the CAH, if needed.


On 8/11/16, at approximately 11:30 a.m. the ORA provided a faxed type copy of MD-B's delineation of surgical privileges and stated they were hanging in the surgical department and she had missed them during the tour.


MD-B's delineation of surgical privileges list dated 2/1/12, indicated MD-B received privileges to perform general surgery which included gallbladder and common duct surgery, simple inguinal hernia repair, vasectomies, and vein stripping. There was a hand written note which read "for [MD-B] OR privileges as of 8/14." However, the delineation of MD-B's privileges failed to include the privilege to perform carpal tunnel surgery, endoscopies, EGDs, colonscopies, and sigmoidoscopies.


On 8/11/16, at 1:30 p.m. the DON verified the MD-B's surgical privileges were not current nor inclusive of all the procedures MD-B performed at the CAH. In addition, the DON confirmed the surgical departments policies and procedures were not current nor updated to identify the current name of the CAH.


On 8/11/16, at 2:35 p.m. RN-D confirmed she had hand written the 8/14, note on MD's privilege list which indicated MD-B's privileges were current as 8/14. RN-D stated she was unable to find documentation approving the identified privileges. RN-D verified MD-B's list of privileges was not current and failed to include all the procedures MD-B was currently performing at the CAH.


The policy and procedure utilized by the CAH titled Clearwater Health Services Scheduling Surgical Procedures revised on 2/08, indicated only those physicians, podiatrists, and dentists who have privileges at the Clearwater County Memorial Hospital may schedule cases in the OR. Current privileges for all surgeons were maintained in the office of the administrative secretary and the surgery department.


The policy and procedure utilized by the CAH titled Clearwater Health Services Aseptic Technique revised 3/08, indicated the surgical department would adhere to appropriate policies for infection control and sterile packages were to be placed in dry areas as moisture could lead to contamination.


A policy related to humidity level controls was not received.

Based on interview and document review, the critical access hospital (CAH) failed to ensure the required 10% sampling of active and closed records had been reviewed as part of the annual CAH evaluation. This had the potential to effect all current and future patients of the CAH.

Findings include:

The CAH's Annual Program Evaluation Report dated 9/15/15, indicated only closed records had been reviewed.

On 8/10/16, at 10:09 a.m. registered nurse (RN)-C, CAH's nurse manager, confirmed the CAH's annual program evaluation dated 9/15/15, lacked a review of active records. RN-C stated the administrative director (AD) and herself had recognized this and both active and closed record review would be included in the next CAH evaluation.

On 8/10/16, at 1:28 p.m. the AD confirmed the CAH evaluation dated 9/15/15, lacked a review of any active records.

On 8/11/16, at 1:36 p.m. the AD confirmed they were unable to verify if the CAH had met the requirement for a 10% review of active and closed records. The AD confirmed the AD was responsible for conducting the annual CAH evaluation.

Although requested, no policy related to annual CAH evaluation was provided.

Based on interview and document review, the critical access hospital (CAH) failed to ensure the CAH policy review, revision had been included as part of the annual CAH evaluation. This had the potential to effect all current and future patients of the CAH.

Findings include:

The CAH's Annual Program Evaluation Report dated 9/15/15, lacked a consistent identification of policy review, revision, and development with the departmental reports included in the annual CAH evaluation.

On 8/11/16, at 1:41 p.m. the administrative director (AD) confirmed the annual CAH evaluation lacked a complete listing of policies which had been developed, reviewed and/or revised. The AD stated the policy review was not standardized and verified the policy review for the 9/15/15, annual CAH evaluation was not completed.

Although requested, no policy related to annual CAH evaluation was provided.

Based on observation, interview and document review, the critical access hospital (CAH) failed to implement an action plan related to the identified humidity control concerns for 1 of 1 surgical suite and sterile supply and equipment storage area to ensure a moisture controlled environment was adequately maintained.


Findings include:


The Quality Study-OR Temperature, humidity, and Positive Pressure Airflow data sheet indicated the operating room (OR) temperature, humidity and airflow was monitored. The objective of the study was to maintain the OR's operating room humidity between 20% and 60%. The results of the study revealed frequent out of range humidity and temperature levels were found. The percentage of days per month the OR humidity levels were within acceptable ranges was as follows:

-5/15: 100%
-6/15: this section was blank
-7/15: 52%
-8/15: 61%
-9/15: 60%
-12/15, through 2/16: 100%

No further study data was available for review.


On 8/10/16, at approximately 8:30 a.m. during the tour of the surgical department with operating central processing technician/operating room (OR) room assistant (ORA) the current humidity was recorded at 67.9%. ORA stated the OR/central supply storage area humidity levels should be between 20-60%. ORA stated if the humidity level was over 70%, staff was to check the OR equipment and supplies for compromised sterilization, however, these checks were not documented. ORA stated surgical/medical procedures were performed at the CAH every Friday.


The Daily CPC Checklist for humidity and temperature monitoring documentation form was reviewed with ORA who confirmed the findings. The checklist indicated the OR humidity levels were to be maintained at 20-60%. The checklist documentation for March, April and May 2016, indicated acceptable humidity levels. The June, July and August 2016, documentation revealed the following:

--June 2016, six of 30 days humidity levels ranged from 67% to 85%. The corrective action section of the form indicated the high humidity levels were reported to maintenance staff on 6/15/16, and 6/18/16. On 6/18/16, the note indicated air conditioning was down to 65 degrees with 66% humidity after air conditioning turned on.

--July 2016, 22 of 31 days the humidity levels ranged from 61%-74%. The corrective action section indicated on 7/3/16, and 7/4/16, the humidity levels were frequently monitored. On 7/4/16, a note indicated maintenance would be notified. A hand written entry dated 7/26/16, indicated humidity levels reported to maintenance, "stated unable to fix at this time."

--August 2016, seven of 10 days the humidity level ranged from 64%-70%. The corrective action section indicated on 8/1/16, the humidity level was reported to maintenance staff.


On 8/10/16, at 11:15 a.m. the director of nursing (DON) stated if humidity levels were not within acceptable parameters, surgery would be canceled. During this interview, the CAH's support services supervisor in charge of the CAH's maintenance department stated he was made aware of the high humidity levels in July at which time the air handlers were "tweaked." He also stated the air handling system was functioning at it's maximum capacity and staff were to monitor the levels. If over 70% staff was to monitor the packaged surgical supplies and equipment to ensure no condensation was present and sterility was maintained. In addition, the DON stated she was unsure if monthly documentation of sterile supply and equipment checks were in place and plans to monitor for trending of compromised equipment and supplies, however, would need to involve the experts.


On 8/11/16, at 9:45 a.m. the plant operation supervisor (POS) who oversaw both Bagley CAH and Bemidji Medical Center's maintenance departments confirmed he was aware of the high humidity levels. The POS stated the CAH's current air system was functioning at is maximum capacity. He stated the facility would need to overhaul the entire HVAC system in order to improve functioning. The POS confirmed there was no current repair work or corrective action plan in place to fix the system. The POS stated as of today, the CAH was looking at redesigning the HVAC system in order to improve functioning and maintain appropriate humidity levels. Although the CAH identified inadequate humidity control concerns, they had not implemented an action plan to correct the source of the issue.


A policy related to the maintenance of humidity levels was not received.