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Based on record reviews and interviews, it was determined that the Condition of Participation (CoP) for Physical Plant and Environment was not met. The facility failed to ensure that both maintenance of equipment necessary to ensure patient safety and the environment where patient care is performed was monitored and sustained within adopted/regulated standards.

Findings include:

This facility has failed to comply with the CoP for Physical Plant and Environment as evidenced by deficiencies identified as follows.

Standard: §485.623(b) also known as C-0222 - Based on observation, interviews and document reviews the facility failed to follow adopted standards to assure proper temperatures of the rinse water in the dishwasher was maintained at all times. The facility failed to take necessary action to assure the systems necessary to maintain minimum water temperatures was operating within manufactures guidelines. It was reported that the facility was aware of this problem and made several attempts to repair the "booster" (the equipment that raises the water temperature to meet the required standard), over a 3 month period, and finally purchased a new booster which at the time of the survey had not been installed. The facility allowed rinse cycles below the minimum temperature to be used without adding a chemical disinfectant to assure the elimination of any harmful organisms. See C-0222 for details.

Standard: §485.623(b)(2) also known as C-0223- Based on observation and interviews the facility failed to assure the proper storage and prompt disposal of trash; See C-0223 for details.

Standard: §485.623(b)(5) also known as C-0226- Based on observation, record review, and interviews the facility failed to assure the temperature, humidity and air exchanges in the operating room was monitored and maintained within the standards adopted by the hospital. The facility failed to take necessary action to assure the systems necessary to maintain temperature, humidity and air exchange was monitored based on documentation provided which showed that for 34 occasions that the air quality was recorded it was outside the temperature range on 28 occasions and was outside of the humidity range on 10 occasions. Additionally it was reported that the air exchange system monitoring was last was recorded in 2002. See C-0226 for details.

Based on the above findings this Condition of Participation was not met.

Based on observations and interviews with key personnel on October 25-27, 2016, it was determined that the facility failed to provide a preventive maintenance program to insure that all essential mechanical, electrical, and patient care equipment were maintained in a safe operating condition.

The findings include:

1. State of Maine Plumbing Code, Chapter 238, Section 11.C.2.e requires that direct connections between potable water piping and sewer connected wastes shall not exist under any condition, with or without back flow protection.

On October 25, 2016 at 11:30 AM, the ice machine in the main kitchen was observed not to have a proper air gap in place in the drain line.

This was confirmed at the time of the observation with the Manager of Nutrition Services.

2. Records for the Dish Machine in the main kitchen related to sanitization/rinse temperature were initially observed to have a number of days that were below the required temperature.

An in-depth review of the dish machine records for the months of August, September, and October, 2016, revealed that 105 of 171 readings were either not recorded or were recorded below the required temperature for the rinse/sanitizing cycle.

This was confirmed with the Director of Facilities on October 27, 206 at 9:00 AM.

3. On October 25, 2016 from 1:00 PM to 3:50 PM, on a tour of the facility with two Maintenance Associates the following was observed:

The doorway to the Patient Registration Room was observed to have a section of floor tile missing, preventing the surface from being easily cleansed or sanitized.

Patient Room 3 contained a chair with tears in the surface of the seat which prevented the surface from being easily cleansed or sanitized.

The above findings were confirmed with the Maintenance Associates at the time of the observation.

4. On October 26, 2016 from 8:55 AM - 1:30 PM, during a tour of the hospital and outpatient buildings, accompanied by the Director of facilities the following was observed:

3 stained ceiling tiles were observed in the sink area of the Emergency Department.

An intravenous pole was observed with rusty casters in the "Stretcher #1" area of the Emergency Department. The rust was preventing the surface from being easily cleansed or sanitized.

At the Sangerville Clinic, treatment room 5contained an exam chair with stitched seams that were observed to be separating, preventing the surface from being easily cleansed or sanitized.

At the Northwoods Specialty Clinic, treatment room 5contained an exam chair with stitched seams that were observed to be separating, preventing the surface from being easily cleansed or sanitized.

The above findings were confirmed with the Director of Facilities at the time of the observation.

Based on observations and interview, it was determined that the facility failed to adequately store and promptly dispose of trash.

The finding includes:

The 2013 State of Maine Food Code, Department of Health & Human Services Health Inspection program 10-144 CMR 200 & Department of Agriculture, Conservation, and Forestry 01-01 CMR 331 states in 5-501.112 Outside Storage Prohibitions: (A) Refuse receptacles not meeting the requirements specified under 5-501.13 (A) such as receptacles that are not rodent-resistant, unprotected plastic bags, or baled units that contain materials with food residue may not be stored outside.

On October 27, 2016 at 10:30 AM, trash bags were observed piled high on the dumpster.

This was confirmed with the Director of Facilities at 10:45 AM. Who stated "Due to the number of isolation patients, the hospital more trash than usual". He also stated, "This happens sometimes", confirming that thefacility was aware that additional trash containers were needed.

Based on a tour of the facility, it was determined that the facility failed to keep the premises clean and orderly.

The finding includes:


1. On October 26, 2016 from 8:55 AM- 9:30 AM, during a tour of the hospital with the Director of Facilities, a cabinet in the Emergency Department area was observed to have dust on the top surface, indicating an uncleaned surface.
This was confirmed with the Director of Facilities at that time.

Based on observation and interviews with key personnel, it was determined that the facility failed to assure that Operating Room (OR): temperatures, humidity, and air exchanges were maintained at adopted standards.

The finding includes:

The current Association of periOperative Registered Nurses (AORN) recommends the following regarding temperatures, humidity, and air exchanges in operating rooms, [AORN Environment of Care 2016]:

· A temperature range of 68-75 degrees Fahrenheit and humidity range of 20-60%.

· The minimum rate of total air exchanges per hour should be maintained at a constant level. With a minimum 15 air exchanges per hour with a recommended range of 20 to 25 air exchanges per hour. [AORN Recommended Practices 9/10/2008].

On October 26, 2016, the temperature and humidity records for the OR were reviewed for the months of April, May, July, August, and September of 2016. Within the date range reviewed, temperature and humidity was recorded on 34 occasions (measured on days when the OR was scheduled to be used). Of those 34 recordings, it was noted that the temperature was outside the acceptable AORN range on 28 occasions and the humidity was outside the acceptable AORN range on 10 occasions.

On October 27, 2016 at 10:00 AM, in a phone interview with the Surgical Services Nurse Manger. She stated that she would log the temperatures and humidity in the Operating Room. If it was too high or low she could adjust the thermostat in the room. If the humidity was too low she would call the Director of Facilities to increase the humidity. If the humidity is too high, she stated they have no way to reduce the humidity. She said it is up to the surgeon as to whether they will continue with the surgery. She reported that the hospital has no written procedure to follow regarding maintaining temperature and humidity levels in the operating room.

On October 27, 2016, the operating room policy was compared to the operating room recording form. Policy # 400-611, Infection Control in the Operating Room, last reviewed 10/15, states in section H. "OR room temperature and humidity, 1. OR room temperature will range between 68-75 degrees. 2. OR humidity will be maintained between 35%-60% per CMS regulations....". The recording form, entitled Daily OR Checks, last revised on January 27, 2016, titles the column for recording temperature and humidity as: "OR ROOM TEMP HUMIDITY" Acceptable range is 68-73 degrees and 20-60% Humidity per AORN standards.


The facility failed to inform the survey team upon entrance that they had elected to use the categorical waiver to allow them to operate at lower humidity levels. CMS requires a humidity range of 35%-60% unless the facility has written documentation that they have elected to use the categorical waiver permitting them to operate with a relative humidity of greater or equal to 20%, but not exceeding 60%. CMS requires that the facility must notify the survey team at the entrance conference that they have elected to use this waiver. (S&C:13-25-LSC & ASC)

On October 27, 2016 at 10:50 AM the Director of Facilities stated that they have no way to monitor air exchanges, and confirmed that the air exchanges in the OR were last checked in 2002.

Based on record review and interviews with key personnel, it was determined that the facility failed to assure that appropriate measures were in place to provide for an emergency supply of food and water.

The finding includes:

On October 26, 2016 at 2:55 PM, the Manager of Nutrition Services stated that they have food and water for at least 3 days for 25 people. This is equal to the total number of patient beds. She stated that they do not have a plan to provide food and water to staff during an emergency.
On October 26, 201616 at 9:00 AM, the Director of Facilities, stated that the food service contract with their primary vender, Performance Food Group, does not have a provision regarding how they would provide food to the hospital during an emergency/disaster.

Based upon on-site observations, interviews, and document reviews conducted by Life Safety Code surveyors, it was determined that the Charles A. Dean Hospital was not in full compliance with 42 CFR §483.70(a), the Life Safety Code.

Please see the Life Safety violations cited on the Centers for Medicare and Medicaid Services (CMS) form 2567 dated November 3, 2016, for the Maine State Fire Marshal's Office Life Safety Code survey.