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Based on observations, interviews, and review of documents and records it was determined that the CAH failed to ensure it was in compliance with applicable State laws and rules related to changes in the building and physical environment. The DSD, kitchen and dining room had been demolished for remodeling and moved to temporary locations in the former outpatient infusion department and two mobile kitchen trailers in the CAH parking lot without the required State of Oregon hospital licensing building plans approval.

The findings identified during the survey reflect the CAH's limited capacity to provide safe and adequate care and services and represent a Condition-level deficiency of CFR 485.608, Condition of Participation: Compliance with Federal, State, and Local Laws and Regulations.

Findings include:

1. Refer to the deficiency cited at Tag C153, CFR 485.608(c), Standard: Licensure of CAH.

2. Refer to the deficiency cited at Tag C220, CFR 485.623, Condition of Participation: Physical Plant and Environment.

Based on observations, interviews, and review of documents and records it was determined that the CAH failed to ensure it was in compliance with applicable State laws and rules related to changes in the building and physical environment. Hospital licensing OAR 333-500-0045, OAR 333-535-0000 and OAR 333-675-0000 include requirements that a hospital submit building construction plans to the SA, the State of Oregon hospital licensing authority, for review and approval prior to building construction or alterations. Impacted areas may not operate until licensing building plans review processes have been completed and approval for the project(s) is received from the SA. The CAH failed to comply as the DSD, kitchen and dining room had been demolished for remodeling and moved to temporary locations in the former outpatient infusion department and two mobile kitchen trailers in the CAH parking lot without the required SA building plans approval.

Findings include:

1. During interview with the CEO and the Facilities Manager on 09/16/2019 beginning at 11:30 a.m. they stated that the DSD, kitchen and dining room had been deconstructed and all equipment removed. The CEO stated that those services had been temporarily relocated to a "lobby annex" area and mobile units in the CAH's parking lot where the provision of food services to patients had begun on 09/03/2019.

The CEO explained that over the last year the DSD and kitchen had experienced water rising above floor level from the floor drain in the dish room. A plumbing inspection identified that the 1957 pipes had significant erosion and required replacement. The CEO further indicated that the extent of the kitchen remodel was still unknown as continuing evaluation of the plumbing system had revealed eroded and deteriorated pipes that extended beyond the dietary department and kitchen. Two unrelated offices adjacent to the department had been affected to date and those offices also relocated to other areas of the CAH.

The CEO stated that in preparation for the plumbing work the CAH had acquired leases for the mobile trailer kitchen unit and the mobile trailer dishwash unit that had been set up in the CAH's parking lot and that a platform or deck had been built up against the CAH to accommodate those. Further, he/she indicated that electricity and water were supplied to the trailers by connections from the CAH and that a large waste water tank had been obtained and connected to the mobile units.

The CEO stated the starting budget for the project was $300,000 and the plan for remodel included replacing the dishwasher, upgrading electrical panels, possibly removing some walls and decorative structures in the dining room, and replacing the entire floor. However, he/she stated the extent of the project was still under evaluation. The CEO confirmed that building plans had not been submitted to the SA and stated that "we should have called" to submit plans for the existing and temporary DSD, kitchen and dining room.

2. A tour of the existing DSD, kitchen and dining room on 09/16/2019 between 12:30 p.m. and 1:00 p.m. with CAH staff revealed that the kitchen and dining room were closed and signs were posted to reflect that the DSD, kitchen and dining room was under construction. The signs identified the name of the general contractor and that the construction project started on 09/03/2019. Evidence of the construction project included:
* The floor throughout the space was in various stages of deconstruction. Linoleum and tiles had been removed and the sub-floor, concrete in some places, was exposed.
* The baseboard throughout the spaces had been removed.
* Ceiling tiles throughout the space were misaligned, stained, or covered with a white material.
* Kitchen equipment, storage units, prep tables, dishwashing equipment, etc. had been removed and pipes, lines and connections were exposed.

3. A tour of hallway and spaces outside of the DSD and kitchen on 09/16/2019 between 12:30 p.m. and 1:00 p.m. with CAH staff revealed two offices unrelated to the DSD that had been emptied and the staff and contents relocated. Those rooms included signs of construction preparation and partial deconstruction. During interview with staff at that time they stated that the pipes under those offices had been found to be eroding and in need of replacement and were to be included in the project. They also disclosed that deconstruction in those rooms had ceased temporarily secondary to the findings of asbestos.

4. A tour of the temporary DSD, kitchen and dining room on 09/16/2019 between 1:00 p.m. and 1:50 p.m. with CAH staff revealed that the current operations were divided between spaces inside the CAH and mobile trailer units parked outside of the CAH in the parking lot. Evidence of the provision of services in the temporary spaces included:

a. Parts of the temporary DSD, kitchen and dining room were accessed through the CAH's main lobby into an area staff described as the former infusion department now referred to as the "lobby annex." The space included:
* A long-narrow table on which three servers were placed that contained food being warmed by six open flame Monogram fuel cans.
* A small commercial type salad bar.
* A bedside dresser type table on which a tray of condiments and salad dressings were placed.
* A small cabinet with drawers on which a crock pot was placed and plugged in.
* Multiple commercial refrigerator and freezer units throughout the spaces, one located in the dining area had a sign posted on it that reflected "Dietary patient use only."
* A long table on which snack foods were displayed for purchase.
* A beverage area located on countertops and cabinets.
* Dry goods storage.
* Dry food storage.
* A cash register and cashier station,
* Numerous round dining tables and chairs.
* A room described as a former patient exam room that was operating as the "diet aide office" for the assembly of patient meal trays. The room contained a refrigerator with food and beverages meal trays, silverware, a computer, etc.
* Numerous DS staff were observed working and numerous other CAH staff and individuals were observed eating.

5. Parts of the temporary DSD and kitchen were accessed from the indoor temporary space through a stairwell to the exterior of the CAH building into a parking lot. The space included:
* A wooden deck or platform was observed up against the exterior wall of the CAH. That deck connected to two long semi-trailer type units. The unit closest to the CAH was described as the kitchen unit and the second unit was described as the dishwash unit. The space between the CAH building exit door and the doors of both units was covered by a tent-type roof comprised of a white plastic material.
* Electricity and water supply lines and connections were observed between the CAH and the two units. A large commercial type waste water tank located on a lower level parking lot behind the units was observed connected to the units. A large commercial type propane tank located behind the units was observed connected to both units.
* The kitchen unit space included cooking equipment, evidence of food prep, a walk-in refrigerator that was full of food, and patient menus were posted.
* The dishwash unit space included dishwash equipment, dish storage, a laundry washer and dryer, a floor sink, and numerous gallon containers of dishwashing products.
* Three stainless steel closed carts were on the deck outside of the units. Those were described by the DSS at the time of the observations as used for transporting food for meal prep between the mobile kitchen and the indoor kitchen, and for transporting patient meal trays to the inpatient units.
* Staff were observed working in both units and transporting the closed carts in and out of the CAH building.

6. Review of SA's hospital licensing building plans records on 09/16/2019 revealed no evidence that building plans for the CAH's existing and temporary DSD, kitchen and dining room had been submitted.

Based on observations, interviews, and review of documents and records it was determined that the CAH failed to ensure that the physical environment was constructed and maintained in a safe, clean, and orderly manner for patients and staff:
* Food being served in the dining room in operation at the time of the survey was being warmed in serving trays by open flames emitted from six Monogram fuel cans. This finding represented an IJ situation. Refer to Tag 000 at the beginning of this SOD report for the details of the IJ identification and removal.
* The existing DSD, kitchen and dining room had been deconstructed in preparation for construction without building plans review and the approval of the SA;
* The DSD, kitchen and dining room spaces in operation at the time of the survey for the provision of food services to patients were located in multiple spaces that included the former infusion department and trailers in the parking lot without building plans review and the approval of the SA;
* The DSD, kitchen and dining room spaces in operation at the time of the survey were disorganized, cluttered, in disrepair, co-mingled with laboratory equipment, and doors from the lab, an inpatient unit, and a bathroom opened directly into the kitchen and dining room spaces;
* There was lack of compliance with the Life Safety From Fire requirements as indicated on the attached Life Safety from Fire CMS 2567 SOD Report.

The findings identified during the survey reflect the CAH's limited capacity to provide safe and adequate care and services and represent a Condition-level deficiency of CFR 485.623, Condition of Participation: Physical Plant and Environment.

Findings include:

1. Refer to the deficiency cited at Tag C221, CFR 485.623(a), Standard: Construction.

2. Refer to the deficiency cited at Tag C225, CFR 485.623(b)(4), Standard: Maintenance - Clean and orderly.

3. Refer to the deficiency cited at Tag C231, CFR 485.623(d)(1), Standard: Life Safety From Fire.

4. Refer also to the deficiency cited at Tag C150, CFR 485.608, Condition of Participation: Compliance with Federal, State, and Local Laws and Regulations.

5. Refer also to the deficiency cited at Tag C270, CFR 485.635, Condition of Participation: Provision of Services.

Based on observations, interviews, and review of documents and records it was determined that the CAH failed to ensure that the physical environment was constructed, arranged, and maintained for patient safety and to provide adequate space for the provision of services. The DSD, kitchen and dining room had been demolished for remodeling and moved to temporary locations in the former outpatient infusion department and two mobile kitchen trailers in the CAH parking lot without the required SA building plans approval.

Findings include:

1. Refer to the deficiency cited at Tag C153, CFR 485.608(c), Standard: Licensure of CAH, that reflects the DSD, kitchen and dining room were operating in spaces not approved by the SA.

2. Refer to the deficiency cited at Tag C278, CFR 485.635(a)(3)(vi), Standard: Infection control and prevention, that reflects the the lack of measures to prevent cross-contamination in the existing and temporary DSD, kitchen and dining room spaces.

Based on observations, interviews, and review of documents and records it was determined that the CAH failed to ensure that the physical environment was maintained in a safe, clean, and orderly manner for patients and staff. The existing and temporary DSD, kitchen and dining room spaces were cluttered, disorganized and dirty.

Findings include:

1. Refer to the deficiency cited at Tag C278, CFR 485.635(a)(3)(vi), Standard: Infection control and prevention, that reflects the the lack of a sanitary environment and measures to prevent cross-contamination in the existing and temporary DSD, kitchen and dining room spaces.

Based on observations, interviews, and review of documents and records it was determined that the CAH failed to ensure compliance with applicable Life Safety from Fire requirements that included:
* Food being served in the dining room in operation at the time of the survey was being warmed in serving trays by open flames emitted from six Monogram fuel cans. This finding represented an IJ situation. Refer to Tag 000 at the beginning of this SOD report for the details of the IJ identification and removal.
* A lack of safe storage for compressed gas.

Findings include:

1. Refer to the findings identified under Tags K522 and K923 on the attached Life Safety from Fire CMS 2567 SOD Report.

Based on observations, interviews, and review of documents and records it was determined that the governing body of the CAH failed to ensure that the CAH was in compliance with all applicable Federal and State laws and regulations and rules that apply to the CAH, including the Conditions of Participation for CAHs.

The findings identified during the survey reflect the CAH's limited capacity to provide safe care and services and represent a Condition-level deficiency of CFR 485.627, Condition of Participation: Organizational Structure.

Findings include:

1. Refer to the deficiency cited at Tag C150, CFR 485.608, Condition of Participation: Compliance with Federal, State, and Local Laws and Regulations.

2. Refer to the deficiency cited at Tag C220, CFR 485.623, Condition of Participation: Physical Plant and Environment.

3. Refer to the deficiency cited at Tag C270, CFR 485.635, Condition of Participation: Provision of Services.

4. Refer to the deficiency cited at Tag C330, CFR 485.641, Periodic Evaluation and Quality Assrance Review.

Based on observations, interviews, and review of documents and records it was determined that the CAH failed to develop and implement appropriate written patient care policies and procedures for the care and services it provided to ensure the provision of safe and appropriate care.

The findings identified during the survey reflect the CAH's limited capacity to provide safe and adequate care and services and represent a Condition-level deficiency of CFR 485.635, Condition of Participation: Provision of Services.

Findings include:

1. Refer to the deficiency cited at Tag C278, CFR 485.635(a)(3)(vi), Standard: Infection control and prevention.

Based on observation, interview, and review of policies and procedures, and other documents it was determined the CAH failed to ensure appropriate infection control and prevention in the existing and temporary DSD, kitchen and dining room spaces in regards to:
* Maintenance of a clean and sanitary environment;
* Measures to prevent cross-contamination;
* Measures to prevent entry of insects, rodents and pests;
* Provisions for handwashing; and
* A water management program to reduce Legionella risk in healthcare facility water systems.

Findings include:

1. A tour of the existing DSD, kitchen and dining room on 09/16/2019 between 12:30 p.m. and 1:00 p.m. with CAH staff revealed that the kitchen and dining room were closed and signs were posted to reflect that the DSD and kitchen was under construction. The floor throughout the space was in various stages of deconstruction. Baseboards throughout the space had been removed, kitchen equipment had been removed and pipes, lines and connections were exposed. Observations included:
* Floors, walls, and other surfaces throughout the space had areas of extensive damage and were covered with a significant build-up of dirt, debris and grime.
* A large window to the exterior courtyard was open and had no screen present to prevent the entry of insects, rodents and pests.
* A stainless steel container of an unidentifiable liquid solution was placed on a countertop in the former cashier area of the department. The solution had layers of beige, gray and green substances present on top of the underlying liquid. A piece of plastic wrap covered the container on which "FR TST 9-2" was written. During interview at the time of the observation the general contractor stated that the container had been there since they began to demolish to kitchen. Hospital staff present during the observation did not know what the contents of the container were.

2. A tour of the temporary DSD, kitchen and dining room, for the provision of food services to patients, on 09/16/2019 between 1:00 p.m. and 1:50 p.m. with CAH staff revealed that the current operations were divided between spaces inside the CAH and mobile trailer units parked outside of the CAH in the parking lot.

a. Observations in the temporary DSD, kitchen and dining room spaces located inside the CAH building included, but were not limited to:
* The unlocked door of a room identified as a bathroom room was located within two to three feet of a dining table and chairs.
* A small unlocked refrigerator with a sign "Patient Food Only" was observed near the entry to the temporary area. The refrigerator was observed to contain numerous bottles of "75 Sundex" described by staff as supplies for the laboratory for patient glucose tolerance testing. The door of the freezer section of the refrigerator could not be easily opened. The freezer had a significant build up of ice in which unidentified containers were imbedded. A container of juice covered in ice was also observed. During interview with staff at the time of the observation they stated that was the lab refrigerator. An unlocked door was observed near the refrigerator with a "Lab" sign on it. The counter on top of the refrigerator contained two placards that listed the food items and prices for the meals being served.
* An unlocked room within the space that had no signage to reflect its use was described as a former outpatient examination room and currently as the "diet aide office." That room contained a computer, a refrigerator in which beverages were observed, meal trays, silverware, etc. Staff explained that the diet aides completed parts of patient meal tray preparation in that room. Clean supplies such as plastic cups were stored directly on the floor underneath the handwashing sink and an unidentified orange liquid was observed in a large uncovered measuring cup immediately next to the handwashing sink.
* Multiple wicker baskets of condiments and five bottles of hot sauces were placed on a countertop immediately next to a clinical sink.

b. Observations in the temporary DSD and kitchen spaces in two mobile units located in the CAH's parking lot included, but were not limited to:
* Countertop, shelf and floor spaces in both the kitchen and dishwash mobile units were crowded and cluttered with food, dirty and clean supplies and equipment, and paper records and documents.
* Uncovered containers of unidentifiable liquids and butter were located immediately next to the front door of the kitchen unit that was propped open and had no screen to prevent the entry of insects, rodents and pests.
* In the kitchen unit dishrags were placed on the top of the cooking grill.
* Numerous containers of spices were stored in the covered deep fryer in the kitchen unit.
* An uncovered garbage can located on the floor underneath the cooking surfaces was overflowing with garbage in the kitchen unit.
* Food, such as pickles, were open and uncovered in the walk-in refrigerator in the kitchen unit.
* A sign that reflected "Handwash sink only" was lying on the top of the laundry washer/dryer however, there was no handwash sink in the dishwash unit.
* There was an extensive layer of pooled water on the floor of the dishwash unit under the dishwashing equipment and assembly. Supplies stored on the floor were sitting in the water.
* The floor of the dishwash unit was a rough, painted wood or wood type material, covered with water, discolored and not readily cleanable.
* A large uncovered bucket full of of waste liquid and food scraps was placed on the floor of the dishwash unit.
* The front and back doors of the dishwash unit were propped open and had no screens to prevent the entry of insects, rodents and pests.

3. A "Construction/Renovation/Demolition/Major Maintenance Pre-Construction and Safety Risk Assessment (PCRA) Form" was dated 09/03/2019 for a "Project name: Kichen (sic) Sewer Replacement." The "Infection Control" section of the form was completed and and the following criteria were answered "Yes:"
* "May generate substantial dust/debris...Yes."
* "May generate noise and/or vibrations that could cause airborne dust, and could affect patient care or clinical procedures...Yes."
* "May impact normal domestic water service...Yes."
The PCRA concluded that "Infection Control has determined that an ICRA Permit is needed...Yes" and "Risk to Patient/Staff: High."

The attached "Infection Control Risk Assessment (ICRA) Permit" dated 09/03/2019 reflected that the "Construction Activity Type" was "Type D: Major duration and construction activities requiring consecutive work shifts" and the "Infection Control Risk Group" was "Group 3: Medium/High Risk" that included kitchens.

4. a. The CMS QSO-17-30-Hospitals/CAHs/NHs letter revised 07/06/2018 was titled "Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease." That "policy memorandum clarifies expectations for providers..." It referred to the USDHHS CDC document titled "Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings" dated 06/05/2017 that reflected that a facilities' water management program should be reviewed and revised "when any of the following events occur:...A major maintenance or water service change occurs, such as: New construction, Equipment changes."

b. Review of the CAH's "Water Safety Management Plan" dated "Last Revised August 2017" included the following "Implementation Actions:"
* "Responsibilities of the Water Safety Management Team" that include "Identify areas where chemical and biological contaminates can enter building's water systems."
* "Provide an accurate description and documentation of the water distribution system/devices" that include "Storage tanks...Sinks...Faucets...Water Heaters...Kitchen Appliances...Pipes, valves, and fittings...Construction or maintenance processes that impacts the water systems..."
* "Assess and document water distribution risk factors" that include "Document locations that require testing...Temperature fluctuations...Water pressure changes. Document location that require observation...Stagnation...External hazards (e.g., construction...)."
* "Monitor and maintain water systems...The facility leaders are responsible for maintaining, monitoring, and testing the water systems and associate equipment. Domestic water outlets and distribution systems shall be monitored routinely to ensure the water is safe for human consumption, clinical operations, and free of biological and chemical contaminant. Monitoring shall be performed...Results shall be recorded."

The "Implementation Actions" were generic and not individualized for PHRMH. Further, the plan had not been reviewed or revised since the identification of the CAH's eroding plumbing system and the subsequent onset of the plumbing related construction and relocation of the dietary department and kitchen to former clinical areas and the parking lot.

c. In a follow-up email from the CAH CEO dated 09/18/2019 at 11:30 a.m., he/she indicated that the CAH had a Water Management Plan to address the reduction of Legionella risk and had done testing in July and August. He/she confirmed that "no additional testing was completed specific to the external water source connection on the main building, the lines to the mobile units, or the mobile units themselves."

Based on observations, interviews, and review of documents and records it was determined that the CAH failed to ensure its program evaluation and quality assurance program was effective and appropriately evaluated the safety and quality of the services provided, to ensure at a minimum, compliance with applicable Federal and State laws and regulations and rules that apply to the CAH and to its staff, including the Conditions of Participation for CAHs.

The findings identified during the survey reflect the CAH's limited capacity to provide safe and adequate care and services and represent a Condition-level deficiency of CFR 485.641, Condition of Participation: Periodic Evaluation and Quality Assurance Review.

Findings include:

1. Refer to the deficiency cited at Tag C150, CFR 485.608, Condition of Participation: Compliance with Federal, State, and Local Laws and Regulations.

2. Refer to the deficiency cited at Tag C220, CFR 485.623, Condition of Participation: Physical Plant and Environment.

3. Refer to the deficiency cited at Tag C270, CFR 485.635, Condition of Participation: Provision of Services.