HospitalInspections.org

Based on record reviews and interviews, it was determined that the Condition of Participation (CoP) for Physical Plant and Environment was not met. The hospital failed to fully implement its plan of correction for Standard: §485.623(B) also known as C-0222, Standard: §485.623(B)(2) also known as C-0223, and Standard: §485.623(B)(5) also known as C-0226.

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 hospital failed to follow adopted standards to assure proper temperatures of the rinse water in the dishwasher was maintained at all times. The hospital 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 hospital 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 hospital allowed rinse cycles below the minimum temperature to be used without adding a chemical disinfectant to assure the elimination of any harmful organisms.

Standard: §485.623(B)(2) also known as C-0223- Based on observation and interviews the hospital failed to assure the proper storage and prompt disposal of trash.

Standard: §485.623(B)(5) also known as C-0226- Based on observation, record review, and interviews the hospital 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 hospital 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.

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