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Based on interview, documentation in 1 of 1 inpatient medical record of a Medicare beneficiary reviewed for the "Important Message from Medicare" (Patient 27), and review of the CMS website, it was determined the hospital failed to ensure it complied with applicable Federal regulations as all Medicare beneficiaries had not been informed of their discharge appeal rights and provided with the "Important Message from Medicare" (IMM) form in accordance with CFR 405.1205.

Findings include:

1. CFR 405.1205, "Notifying beneficiaries of hospital discharge appeal rights", was reviewed on the electronic CFR website. It included the following:

* CFR 405.1205(a) reflected that "For purposes of §§ 405.1204, 405.1205, 405.1206, and 405.1208, the term "hospital" is defined as any facility providing care at the inpatient hospital level, whether that care is short term or long term, acute or non acute, paid through a prospective payment system or other reimbursement basis, limited to specialty care or providing a broader spectrum of services. This definition includes critical access hospitals."

* CFR 405.1205(b) required that "Advance written notice of hospital discharge rights. For all Medicare beneficiaries, hospitals must deliver valid, written notice of a beneficiary's rights as a hospital inpatient, including discharge appeal rights. The hospital must use a standardized notice, as specified by CMS, in accordance with the following procedures: (1) Timing of notice. The hospital must provide the notice at or near admission, but no later than 2 calendar days following the beneficiary's admission to the hospital ... (3) When delivery of the notice is valid. Delivery of the written notice of rights described in this section is valid if- (i) The beneficiary (or the beneficiary's representative) has signed and dated the notice to indicate that he or she has received the notice and can comprehend its contents, except as provided in paragraph (b)(4) of this section; and (ii) The notice is delivered in accordance with paragraph (b)(1) of this section and contains all the elements described in paragraph (b)(2) of this section ..."

* The CFR provides additional requirements for a subsequent copy of the signed IMM to be provided to the beneficiary again prior to discharge if applicable.

2.a. The medical record for Patient 27 who was admitted to the inpatient unit on 01/13/2023 @ 2210 and expired in the hospital on 01/20/2023 was reviewed. Their date of birth was 03/07/1941 and they were 81 years of age. There was no documentation in the record to reflect the patient had been provided with the IMM form within two calendar days of admission, nor at all during the seven day hospitalization as required.

2.b. During interview with the CID at the time of the record review on 07/12/2023 beginning at 1325 they confirmed there was no evidence of the IMM form in Patient 27's record.

2.c. In a follow-up email from the CID received on 07/13/2023 at 1020 they further wrote that they "Could not locate [the IMM form] in chart" for Patient 27.

Based on observations, interviews, and review of fire safety and emergency preparedness policies and procedures and documentation, it was determined that the CAH failed to fully develop and implement policies and procedures to ensure compliance as indicated on the attached Life Safety from Fire CMS 2567 SOD report for Building-01, the main hospital, and on the CMS 2567 SOD report for Emergency Preparedness.

Findings include:

1. Refer to the findings on the Life Safety from Fire CMS 2567 and the Emergency Preparedness CMS 2567 reports.

Based on observation, interview, and review of P&Ps it was determined that the CAH failed to fully develop and implement P&Ps that ensured that the pharmacy was organized and free of clutter, that drugs were appropriately managed and labeled; and that expired or otherwise unusable drugs were not available for patient use:
* The pharmacy was disorganized and cluttered.
* Drugs and biologicals were not properly stored in accordance with the CAH P&Ps.
* Drugs and biologicals available for patient use were not appropriately verified and labeled in accordance with the CAH P&Ps.

Findings include:

1. A policy titled "Drug Outlet Policy and Procedures for the Pioneer Memorial Hospital Drug Room" dated as "Last Approved 07/2023" was reviewed and reflected:
* "Storage ... The Pharmacy Department is responsible for the proper storage of all medications according to the manufacturer's package insert and USP guidance. Proper storage conditions must be met, including but not limited to temperature, light, humidity, sanitation, ventilation, security, and space considerations. Correct storage conditions must be maintained at all times, including during shipping and transfer."
* "The pharmacist will supervise all areas of the hospital where drugs are stored. This includes the drug room ... Inspections of these areas will be conducted every two months by pharmacy staff ... to ensure that there is proper drug storage ..."
* "Non-scheduled room temperature medications in the drug room are further organized by injectable and oral/noninjectable sections, each of which is kept in alphabetized bins. The bins are to facilitate cleaning and disinfection."
* "Damaged or expired drugs will be quarantined within the drug room in either the locked outdate cabinet (for any controlled substance) or the unlocked cabinet outdate cupboard (non-controlled medications) ... Quarantined drug storage areas are to be clearly marked."
* "The pharmacist or pharmacist technician shall order formulary medications on an as needed basis ... Non-formulary medications may be ordered on a case-by-case basis."
* A medication that is only available in the drug room (typically select refrigerated outpatient medications or non-formulary medications) may be removed for dispensing by the charge nurse upon a provider's order."
* "Quarantined drugs will be removed from the drug room via reverse distribution provided by a DEA-registered distributor licensed in the State of Oregon."
* "QA items include Monitoring of drug storage areas ... auditing of controlled substance transactions and storage conditions of all medications are appropriate."

The P&P was unclear and lacked complete information specific to outdated and non-formulary medications. For example, where the policy stated "Proper storage conditions must be met, including but not limited to temperature, light, humidity, sanitation, ventilation, security and space considerations ..." and "Monitoring of drug storage areas ... auditing of controlled substance transactions and storage conditions of all medications are appropriate" it was not clear whether "all medications" included non-formulary medications or outdated medications. Further, it was unclear whether the organization of medication by type, "injectable and oral/noninjectable" and alphabetization also applied to outdated medications.

2. A tour of the Pharmacy Department was conducted with the PIC and the CPT on 07/11/2023, beginning at 15:45. The PD participated by phone. During the tour, it was observed that the Pharmacy was cluttered, disorganized, and lacked adequate space for storage of medications. The pharmacy space was inadequate for proper medication storage, large office items impeded access to staff work areas, and storage cabinets were excessively full. For example:
* Various cardboard boxes, Styrofoam boxes and plastic totes were stacked on top of cabinets, approximately 8-10 inches from the ceiling.
* Other cardboard boxes and plastic totes were stored on the floor, under workstations, and on counter tops.
* One of the two sinks had a wooden board placed over the basin. On top of the board and off to the side were various drug guides and other reference books, loose papers, three packages of injectable medications that were unopened and one empty medication package. The PIC stated at the time of the observation that the area was being used as a "work station" due to a lack of space in the pharmacy. A large, 32 gallon, uncovered garbage can was placed directly in front of the "workstation" sink which had to be moved in order to use the "workstation", and to access the medication storage cabinet underneath the sink.
* A mixture of expired medications, and expired cleaning supplies were observed under the "workstation" sink cabinet. These items were piled up to the front edge of the cabinet doors and almost to the top of the cabinet. Additionally, several loose vials of injectable medications were observed laying on their sides in piles at the bottom of the cabinet, as well as other bottles of medications, small boxes of medications, and loose push packages of pills. Medications were piled up to the drainage pipe of the sink and spilled down around expired cleaning products. A cardboard box and a visibly full paper bag were also observed at the very back of the cabinet. No designated sections by drug type or alphabetized bins were observed as described in the hospital's policy. Although there were no visible signs of water damage, it was unclear whether environmental controls for temperature and humidity were considered or monitored.
* A second locked cabinet, measuring approximately 72 inches x 18 inches, labeled "Expired Medications" was observed directly left of the Pharmacy entrance. When the surveyor asked that it be opened, the CPT stated, "Be careful. Something might fall out." Observed was a full cabinet with approximately nine medium-sized cardboard boxes, several unboxed vials of medication, loose push packages of pills, and packages of other medications that were piled on top of the cardboard boxes and each other. Seven to ten bags of IV solutions were also observed wedged between boxes and other medications on three separate shelves in the cabinet. There was no apparent order observed, and no designated sections by drug type or alphabetized bins as described in the hospital's policy. Shelves that were labeled included: "cut down trays ... surgical trays ... infusion pumps ... burn sheets ..."
* A third area with outdated medication was noted under a workstation. A red plastic tote was observed on the floor, approximately 2 inches from an open garbage can and approximately 6 inches from the work station's chair where the CPT had been sitting at the beginning of the tour. Inside the red tote were approximately nine IV solution bags of potassium chloride. On top of the tote was a 1-page sheet of paper with a handwritten note, "Not on formulary do not use". Upon further inspection, the surveyor noted that the IV solution had an expiration date of "May 2023". Shortly afterwards it was observed that the CPT placed another handwritten note on the IV bags with the word "outdated".

The hospital failled to fully implement the CAH P&P for drug and biological storage, including but not limited to "temperature, light, humidity, sanitation, ventilation, security and space considerations ...", and outdated drugs were available for patient use. For example:
* Outdated medications were stored under a sink, an area that does not meet nationally recognized standards as a clean and sanitary environment. The humidity level, temperature, and ventilation under the sink were not monitored and therefore it was unclear whether that cabinet met storage requirements for the storage of drugs and biologicals.
* Non-formulary IV solution bags which had a potential for patient use were stored in an unsanitary area under a workstation desk, on the floor near an employee's feet and an open garbage can.
* The IV solution bags referenced above were mislabeled, had not been identified as "outdated", and were not stored in a designated and clearly marked "Quarantined drug storage" area.
* Space considerations were not met as evidenced by medication vials, bottles and pill packages falling on top of other items in the dedicated, locked cabinet and the use of the cabinet under the sink for drug storage.
* Both outdated medication storage areas were disorganized and the outdated medications were not stored by type, "injectable and oral/noninjectable", or alphabetized per the CAH P&P.

3. During an interview with the PD, PIC, and the CPT at the time of the observation, the PIC and the CPT confirmed Finding 2. When asked about the storage of outdated medications, the PIC stated that the hospital had a contract with an approved DEA-registered company who comes and picks up the outdated medication, but that they had not been in the area for "awhile". The PIC acknowledged that the storage areas for outdated medications were inadequate and stated that it had been brought to the attention of hospital administration, however, the storage situation remained the same. When asked about the bags of potassium chloride IV solution stored under the workstation on the floor, the CPT stated that they were non-formulary, and that they were "clearly marked" so would not be available for patient use because they were "non-formulary". When asked what "non-formulary" meant, the CPT stated that some medications were not approved for patient use, however, they were keeping them until a formal decision could be made, and that once a decision was made, the non-formulary medications could potentially be made available to patients.

Based on interview, review of the CAH's lists of services furnished under contract, arrangement or agreement, and its list of 2022 contract evaluations it was determined that the CAH failed to conduct evaluations of services furnished under contract, arrangement or agreement.

Findings included:

1. A "Contractor Evaluation List - 2022" lacked documentation to reflect that all entities or organizations identified as providing services under contract, arrangement or agreement had been evaluated in 2022. That was confirmed during review of contracted services with the CEO on 07/13/2023 beginning at 1125 when they stated that evaluations of all such entities or organizations had not been conducted in 2022. The CEO further stated that those that were not done included: Physician Practice Specialists for credentialing services, Good Shepherd Medical Center for blood compatibility testing services, ECG and Holter services, and others.

29708


Based on interview and review of medical record documentation for 2 of 2 patients reviewed for care plans (Patients 14 and 27), it was determined the CAH failed to ensure a nursing care plan was developed, implemented and kept current for each patient based on assessment of the patient's individualized needs.

Findings include:

1.a. Medical record documentation for Patient 14 reflected the patient was admitted to the hospital on 02/09/2023 with diagnoses including CVA and dysphagia. The record reflected the patient had skin alterations including skin tears and pressure ulcer. Examples included:
*A "Nurse Note" dated 06/18/2023 at 1023 reflected the patient had a 2cm X 3cm skin tear to right forearm with "Purple Periwound ... Pale Pink Wound Bed" and "Drainage ... Scant Yellow."
* An RN note dated 06/25/2023 at 1005 reflected "... Right Forearm ... Skin Tear ... Medihoney and Foam ..."
* A "Nurse Note" dated 06/26/2023 at 1824 reflected "patient up in [their] WC ... Dressing on skin tear dated 6/25 intact on forearm ..."
* An RN note dated 06/30/20233 at 0419 reflected "4cm Skin tear RFA. pt states [they don't] know how [they] might of gotten the tear, cleansed with skin cleanser, steri-strips, 4x4 gauze and roll gauze applied ..."
* A CNA note dated 07/02/2023 at 0353 reflected "... [RN] cleaned and rebandaged skin tears on right forearm ..."
* A "Nurse Note" dated 07/09/2023 at 1258 reflected.
- "L lateral malleolus - non blanchable redness and small scab at center. NO drainage. painful per patient"
- "R great toe tip non blanchable redness"
- "L middle toe, middle joint, underside - cracked skin with small amount of bleeding NO active bleeding"
- Type of Wound ... Pressure Ulcer"
- "R great toe ... Stage I ..."
- "L lateral ankle ... Stage II ..."
- "both feet washed with wound cleaner and inspected for skin breakdown. dressings applied and dated. Heavy moisturizer applied to very dry skin on both feet and ankles."
* An RN note dated 07/09/2023 at 2023 reflected "Dressing clean/dry intact, Covered by dressing, Skin tear."

1.b. Review of Patient 14's care plan titled "In Room Quick Care Reference" dated "Last Updated: 7/11/23" reflected no information about the patient's skin alterations, including no goals and no individualized interventions. The record contained no other nursing care plan.

1.c. During an interview and review of the medical record on 07/13/2023 at 1430, the DNS confirmed the findings in Patient 14's medical record and care plan.

2.a. An ED physician report dated 01/13/2023 at 1931 reflected Patient 27 presented to the hospital on 01/13/2023 with problems that included "progressive weakness" and "gagging when [they] tried to eat." Laboratory tests reflected altered lab values. The ED physician recorded "Assessment - 1. Severe hypercalcemia 2. Acute renal insufficiency. Plan of Treatment - Patient will be admitted and maintained on IV fluids, calcitonin ... labs will be repeated in the morning. I advised [family] that this is an admission that will probably take 2 or 3 days at a minimum ... Patient ... does not want CPR if [their] heart should stop ..."

* A physician noted dated 01/14/2023 at 0847 reflected that "Overnight [Patient 27] had some low oxygen saturations and was started on nasal cannula oxygen ... some episodes of vomiting, and that improved after another 4mg IV Zofran ... noted to be in atrial fibrillation with rate sometimes into the 130's. I suspected that this was a chronic condition based on the fact that she was on Eliquis, and review of the records indicated this to be the case."

During the course of the hospitalization the record additionally reflected Diagnoses that included Congestive Heart Failure and Dementia, and due to rapid deterioration the family chose comfort care measures. Patient 27 passed away in the hospital on 01/20/2023.

2.b. The nursing "Care Plan Report" for Patient 27 contained only one problem: "Risk for Electrolyte Imbalance" dated as initiated on 01/13/2023. The "Outcomes" was "The patient will have normal laboratory values ... stable vital signs ... not exhibit signs and symptoms of electrolyte imbalance." The only care plan "Interventions" were "Administer medications and electrolyte replacement products as ordered, and monitor for effect ... Assess for signs and symptoms of electrolyte imbalance."

The nursing care plan for Patient 27 was not complete as all of the patient's nursing problems and needs were not identified, including but not limited to:
* "Weakness" and "comfort care measures" that impacted the patient's ability to ambulate, transfer, reposition self in bed and chair, and perform ADLS such as hygiene, toileting, eating, etc. and created potential for complications such as pressure sores, infection, injuries due to falls, weight loss, emotional stress.
* Cognition and memory challenges secondary to condition and dementia that impacted the patient's ability to follow instructions and perform ADLs safely.
* Oxygen administration via nasal cannula that had safety risks and created potential for complications such as skin alterations.
* Administration of IV medications/fluids that created potential for complications such as infection and skin alterations.

2.c. During interview with the CID on 07/12/2023 beginning at 1325 they confirmed Patient 27's care plan contained only the one problem.







44104

Based on interview and review of medical record documentation for 5 of 5 patients reviewed for completeness and accuracy (Patients 24, 25, 26, 27, and 28) it was determined the hospital failed to ensure that all medical records were legible, clear, and complete. There were blank spaces on forms, required information was not documented, and entries in the records had been altered with "write-overs."

Findings include:

1. Review of the medical record for Patient 24 reflected they received a blood transfusion on 05/01/2023 at 0525. The transfusion record lacked the time the blood was removed from the laboratory blood bank to be transported to the patient unit, and it lacked the volume of blood transfused. Those items were not recorded in the specified spaces on the transfusion form.

2. Review of the medical record for Patient 25 reflected they received a blood transfusion on 05/26/2023 at 1155. Entries on the form had been altered by "write-overs."

3. Review of the medical record for Patient 26 reflected they received a blood transfusion on 05/22/2023 at 1600. Entries on the form had been altered by "write-overs."

4. Review of the medical record for Patient 27 reflected that the patient expired at the CAH on 01/20/2023. The untitled organ donor request form contained the following sections that had not been completed and the spaces for which were blank: "Any history of AIDS/HIV, Hep B or C, Cancer, Positive Blood Cultures (most recent), or Alzheimer's"; "Blood Cultures (when & reason)"; and "Ocular History." Further, entries recorded in the bottom margin of the form included the first name of an unidentified person, an 8 digit number, and "1305 potential donor" and "1310 not a donor." It was unclear who wrote those and what those meant.

5. Refer additionally to the findings for Patients 24, 25, 26, 27 and 28 related to medical records completeness under Tags C-812, C-1050, C-1110, C-1118 and C-1503.

Based on interview and review of medical record documentation for 2 of 3 patients who received blood transfusions (Patients 24 and 25) it was determined the hospital failed to ensure medical records contained evidence of properly executed consent forms for those services.

Findings include:

1.a. Review of the medical record for Patient 24 reflected they received a blood transfusion on 05/01/2023 at 0525. There was no documentation in the record to reflect the patient's written and informed consent for the transfusion.

1.b. During interview with the CID at the time of the review on 07/12/2023 beginning at 1115 they confirmed the record did not contain evidence of the blood transfusion consent form.

2.a Review of the medical record for Patient 25 reflected they received a blood transfusion on 05/26/2023 at 1155. There was no documentation in the record to reflect the patient's written and informed consent for the transfusion.

2.b. During interview with the CID at the time of the review on 07/12/2023 beginning at 1155 they confirmed the record did not contain evidence of the blood transfusion consent form.

Based on interview and review of medical record documentation for 3 of 3 patients reviewed for authentication (Patients 24, 26 and 27) it was determined that the hospital failed to ensure that all entries in the medical records were authenticated, dated, and timed.

Findings include:

1. Review of the medical record for Patient 24 reflected they received a blood transfusion on 05/01/2023 at 0525. The transfusion record lacked signatures/authentication by staff in the specified space on the form that required two signatures to verify the correct blood was issued to be transfused to Patient 24.

2. Review of the medical record for Patient 26 reflected they received a blood transfusion on 05/22/2023 at 1600. The transfusion record lacked the date and time in the specified space on the form that required the date and time that two staff verified that the correct blood was issued to be transfused to Patient 26.

3. Review of the medical record for Patient 27 reflected that the patient expired at the CAH on 01/20/2023. The untitled organ donor request form lacked the signature/authentication by the staff who completed the form, and it lacked lacked the date and time the form was completed including entries made in the bottom margin of the form.

4. During interview with the CID at the time of the medical record review on 07/12/2023 beginning at 1010 they confirmed the lack of authentication and dates and times in the medical records.

29708




44104

Based on observations, interview, documentation in 4 of 6 employee TB screening records (Staff 15, 16, 18 & 19), review of infection control P&Ps, and other documentation, it was determined that the CAH failed to ensure it had developed and implemented infection prevention P&Ps that demonstrated adherence to nationally recognized infection prevention and control guidelines, and to ensure it maintained a clean and sanitary environment in the following areas:
1. Annual IC Risk Assessment was not complete and risks were not thoroughly evaluated.
2. Annual TB risk assessments had not been conducted.
3. Annual IC Plan was not fully developed or implemented.
4. TB Exposure Plan was not fully developed or implemented; TB screening for employees and contracted staff were not complete or timely in accordance with hospital P&Ps and CDC recommendations.
5. Waterborne Pathogens Management Plan was not fully developed or implemented.
6. P&Ps to ensure a clean and sanitary environment, including P&Ps for instrument/device pre-cleaning, disinfection and sterilization processing, were not fully developed, implemented, and were inconsistent with nationally recognized standards.
7. Cleaning products, hand hygiene products, and patient care supplies and equipment were expired, unlabeled, and were not maintained in a clean or sanitary manner, including reusable patient care items identified for sterilization.
8. Drugs and biologicals were stored in a manner inconsistent with nationally recognized infection control standards.
9. Undated glucometer control vials were left available for use to validate accuracy of POCT for patient care.
10. Food handling and storage was not in accordance with clear or complete P&Ps to ensure prevention of food-borne illness.

Findings included:

1. The hospital's annual "Infection Prevention Risk Assessment" dated "January 2023" was reviewed and reflected:
* The risk assessment contained several rows with the following categories: "HAI: Device Related ... HAI ... Targeted Processes ... Emergency Management ... Environment of Care ... Communicable Disease Risks".
* The key at the beginning of the assessment included the following risk score ratings:
- "Probability of event ... 3 = Frequent, 2 = Occasional, 1 = Rare"
- "Morbidity/Mortality ... 3 = High, 2 = Moderate, 1 = Low"
- "Preparedness ... 3 = New Guideline, 2 - In Progress, 1 = In Place"
- "Required by Law, Regulation ... 1 point each"
- "Institutional Risk (financial, legal) ... 3 = High, 2 = Moderate, 1 = Low"
- Met Prior Years [sic] Goal ... 3 = Did not meet, 0 = Met"
- "Risk Score ... Priority Level 12 - 18 HIGH ... 7 - 11 MODERATE ... 1-6 LOW"
* Of the twelve risk area/items listed on the risk assessment, only one, "TB transmission" had documented risk scores, including a "1" in the "Required by Law, Regulatory" category, and an overall "Risk Score" of "5".
* The risk area titled "Risk of Ventilator Associated Pnuemonia [sic]" [VAP] did not reflect any risk scores, and the other ten risk areas listed had a "1" in the "Required by Law, Regulatory" score field but no other scoring documented in any of the other scoring fields.
* Eleven of the twelve risk areas/items listed, [VAP excluded], included a space for data from previous years, including some data from "2014". However, no data for "2022" had been documented for any of the twelve risk areas, and the HCP flu vaccination rate risk area had no data for any of the years listed, which were 2017 - 2022.
* The listed risk areas were color coded, and the color coding key indicated that red highlighting denoted "HIGH" risk, yellow denoted "MODERATE" risk, and green denoted "LOW" risk. Ten of twelve items listed were color coded as "green", and two, the "Risk of Infection ... due to Hand Hygiene", and "... (HCP) Influenza Immunization" were color coded as "yellow".

The hospital failed to document that a complete and thorough risk assessment had been conducted as described in the "Infection Control Plan - Morrow County Health District" policy, refer to Finding 2, the Infection Control Plan. For example, it was unclear whether the annual Infection Prevention Risk Assessment had been completed as the previous year's (2022) data had not been included, scoring in the risk determination fields had not been documented for eleven of twelve risk areas, and a final overall "Risk Score" had not been calculated for the same eleven risk areas/items. It was unclear how the hospital determined that both "Hand Hygiene" and "(HCP) Influenza Immunization" were a moderate risk, or how the other categories had been determined as low risk when no data was documented. It was unclear how the "TB transmission" risk had been determined to be "LOW" when a TB risk assessment had not been documented by the hospital although the Infection Prevention risk assessment stated, "Conduct annual TB Risk Assessment". Refer to Findings 2. and 2.a., failure to provide TB Risk Assessments, and the hospital's acknowledgement that documentation was unavailable.

2.a. The hospital failed to conduct an Annual TB Risk Assessment as part of nationally recognized infection prevention and control program standards.
* The hospital was unable to provide documentation that an annual TB risk assessment had been conducted for 2022 and 2021.

2.b. In a follow up interview with the IPD via text on 07/13/2023, the IPD stated "I was not able to locate the annual TB risk assessment or infection control audits for [sic] past 2 years."

3. A document titled "Infection Control Plan - Morrow County Health District" dated as "Last Revised 08/2022" was reviewed and reflected:
* Under "Procedure ... Infection Prevention Program ..." was written: "Infection Prevention activities include but are not limited to ... consultation regarding the purchase of equipment and supplies used for sterilization, disinfection, and decontamination purposes and reviews cleaning procedures, agents, and schedules used throughout the organization. Consults with departments regarding changes in cleaning products or techniques ... Assessment of educational needs and development of appropriate orientation and in-service programs ... Consultation with hospital staff regarding development of policies and procedures to prevent and control healthcare acquired infections ... Implementation of organization wide infection prevention practices based on surveillance data and evidence-based practice ... Risk assessment, including ongoing assessments to identify risks for the acquisition and transmission of infectious agents by using an epidemiological approach that consists of surveillance, data collection, and trend identification. Effectively implement infection prevention and control processes based on risk. A formal risk assessment is performed annually and as needed ..."
* Under "Infection Prevention Committee" was written: "Purpose: The Infection Prevention Committee is responsible for the implementation of the Infection Prevention Plan ... Duties ... Conducts ongoing surveillance to identify trends of epidemiological significance ... CDC criteria are utilized to define health care associated infection and establish target thresholds ... Reviews and approves Infection Prevention policies ... Provides oversight for staff, provider and patient education related to Infection Prevention ... Serves as a resource to all personnel and departments for Infection Prevention practices ... Ensures Infection Prevention participation in the program to monitor the physical building for compliance with safety and cleaning policies."
* Under "Responsibility" was written: "The Infection Prevention Officer is responsible for the monitoring of healthcare associated infections and instituting effective control measures where appropriate. Other activities include ... overseeing the staff and environment for compliance with all infection prevention policies and procedures ...".
* Under "Areas of Care" was written: "Hospital-wide services, including Emergency Department, Imaging Services, Laboratory, Respiratory Therapy and Nursing Departments".

The hospital failed to fully developed and implement its Infection Control Plan that was based on a current and complete hospital-wide infection control risk assessment. It was unclear how the annual IC Plan was developed when the IC program had not conducted a review of the previous year's IC surveillance data and identified risks based on that data as per the hospital IC plan and nationally recognized standards. Refer also to Findings 1. and 2., the hospital's failure to conduct annual Risk Assessments. The hospital failed to fully implement its Infection Control Plan which stated that IP was responsible to ensure "the monitoring of healthcare associated infections and instituting effective control measures where appropriate. Other activities include ... overseeing the staff and environment for compliance with all infection prevention policies and procedures ...". For example, expired cleaning supplies were found throughout the hospital, uncleanable surfaces were not repaired, clean and dirty patient care equipment were intermingled, and manufacturer IFU's on the cleaning and care of patient care equipment were not followed. Refer to Findings 7.b. and 8, observations during tours of the Medical Unit and the Pharmacy.

4.a. A document "Mycobacterium Tuberculosis Exposure Control Plan" dated "Last Approved 12/2021" was reviewed and reflected:
* Under "Administrative Controls" was written, "The Infection Prevention Department, under the direction of the Infection Prevention Committee, will ... Conduct an annual risk assessment as outlined by the Oregon Public Health Authority, TB Program ... "
* "Nursing will ... Conduct Baseline TB Screening ... All new HCW will receive the following: A Risk Assessment ... A TB Symptom Screen ... Baseline TB Testing ... If the HCW has no history of positive TB screening or testing ... The RN will provide a baseline two step Mantoux tuberculin skin test ... or refer the HCW to the laboratory to collect an IGRA ..."
* "The nurse will complete the 'HCW TB Testing' form. The completed document will be retained within the HCW medical file ... "
* "TB Surveillance - Frequency ... The Infection Prevention Department will conduct a Tuberculosis Risk Assessment on an annual basis ... Based on results of the TB Risk Assessment, a risk classification according to CDC guidelines will be assigned ... to determine the need and frequency for a TB screening and surveillance program ... The risk classification has the potential to change at any time depending on the results of the annual TB risk assessment."

4.b. The hospital failed to fully develop and implement a TB Exposure control plan that was based on the hospital's Annual TB Risk Assessment. Refer to Findings 2. and 2.a., the hospital's failure to provide documentation of a TB risk assessment for the past 2 years, and the IPD confirmation of that finding, Finding 2.

4.c. The hospital failed to implement its TB exposure control plan as written. For example, employee records for TB screening and testing were reviewed and reflected:
* The TB baseline screening records were reviewed for Employee 15. The hospital could not provide documentation that baseline TB testing had been conducted for Employee 15 per hospital policy.
* The TB baseline screening records were reviewed for Employee 16. The hospital could not provide documentation that baseline TB testing had been conducted for Employee 16 per hospital policy.
* The TB baseline screening records were reviewed for Employee 18. The employee had a negative TB blood test (IGRA), however, the hospital could not provide documentation that the required "HCW TB Testing" form had been completed for Employee 18 per hospital policy.
* The TB baseline screening records were reviewed for Employee 19. The hospital could not provide documentation that baseline TB testing had been completed for Employee 19. A negative first-step TB skin test was documented on "9/13/18". The hospital, however, was not able to provide documentation that a second-step TB skin test was performed as part of the "baseline two step Mantoux tuberculin skin test" required per hospital policy. Additionally, the hospital could not provide documentation that the required "HCW TB Testing" form had been completed for Employee 19.

4.d. During a follow up interview with the IPD on 07/13/2023 at approximately 1140, Findings 4 - 4.b. were confirmed.

5. A 4-page, undated document titled "Prevention of Legionella" was reviewed and reflected:
* "Purpose ... To establish a management program for Pioneer Memorial hospital which reduces the risk for Legionnaire's Disease associated with the hospital's water system and devices according to ASHRAE."
* "Procedure ... Survey the facility and identify any areas or devices that have the potential risk to promote the growth or spread of Legionnaire's Disease ... Develop and maintain a water management program that evaluates the facility's water system, including temperature, pressure, and quality and processes such as heating, storing and filtering water ... Weekly use of a [sic] aquapro water tester for monitoring temperatures, TDS, and quality ... Reduce the buildup of biofilm on any surface that is constantly moist, weekly cleaning with appropriate disinfectant required by manufacturer recommendation. This includes the following: ... water filters ... shower heads and hoses ... infrequently used equipment, including eyewash stations ... ice machines Use of disinfectants with appropriate range of pH ... Prevent water stagnation due to reduced occupancy or for unused fixtures/toilets ... Weekly run of water through pipes ... or flush unused toilets ... maintain appropriate water temperature for hot water heaters ... Maintain ice machines according to manufacturer's recommendations ... Maintain backflow systems ... including backflow to endoscope cleaning machine, sprinkler system. Inspect system annually according to regulations ... Maintain verification of the hospital's water management program on a continuous basis ... Provide documentation of the processes established ... to verify appropriate disinfection process or control levels are followed ... In the event, there is suspension [sic] a patient may have a healthcare-associated pneumonia, Legionnaire's Disease, the patient must be tested according to recommendations. If the patient tests positive, the local and/or state health department will be notified and necessary steps will be taken as recommended ... Review of the hospital's water management program will be conducted annually ..."
* Included in the "Prevention of Legionella" policy was a 1-page, undated document titled "Pioneer Memorial Hospital Building Water System" which described the flow of water from a "municipal water line" that was directed to the "water softer" [sic] then to "sinks/showers ... ice machines, drinking fountains, whirlpool tub, instant hot in kitchen and utility room, Lab water system ... wash machine, and Endo room." It further described "two propane gas fired boilers" that heated water for distribution to "multiple hot water heaters" supplying a 650-gallon circulation tank which also supplied hot water to the hospital. The attachment also described the distribution of hot water via "recirculating lines" and "non-recirculating" lines.
* The last page of the policy was titled "Pioneer Memorial Hospital" and provided a diagram of the water flow from "Municipal Water" through to "Sanitary Sewer". A key at the bottom of the diagram reflected: "A-Temperature Permissive B-Stagnation C-No Disinfectant D-External Hazards E-Conditions for Bacteria Spread F-Special Considerations for Healthcare"

The policy was not fully developed or implemented. For example, the policy was undated and therefore it was unclear when the hospital had implemented its Water Management Plan, or when it was last reviewed, revised, or updated. Key stakeholders, such as the Infection Prevention Committee, were not listed to ensure that the procedures had been evaluated for any infection control risks. It was unclear when the water flow description and the water flow diagram had last been reviewed, revised or updated. For example, it was unclear whether the water flow information had been updated since the Endoscopy room and related services had been discontinued, refer to Finding 7.b., Medical unit tours and observed "Endoscopy" room being used as storage. It was not clear whether a facility water management risk assessment had been conducted, or how often that assessment was required to occur to identify risks of where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. The plan did not describe corrective actions to prevent potential transmission of disease when values outside of control limits were not maintained. Failure of control measures such as fluctuation in water temperatures, pH out of range, inadequate disinfection, or failed water quality tests were not addressed. Rather, the plan described actions that occurred once a patient had been identified as being suspected of "Legionnaire's Disease", and then actions listed were to test the patient and report to local health authorities and follow recommendations. Other follow up actions such as investigating, identifying, and implementing systemic control measures of potential waterborne pathogen sources were not described. The policy did not address a contingency response when unexpected changes in the system occurred, such as, new construction, a water main break, introduction of new equipment, i.e., water heater replacement, or when Legionella was identified in the hospital's water system.

6.a. The policy titled "Cleaning Shared Patient Care Equipment Guideline" dated last approved "07/2023" was reviewed and reflected:
* "Clean patient care equipment is the responsibility of all Pioneer Memorial Hospital ... staff"
* "Staff are required to follow manufacturer's instructions/procedures for cleaning specialised [sic] patient care equipment to ensure correct cleaning requirements are met and the equipment is not damaged by inappropriate use of chemical products."
* "Any non-critical reusable equipment that come into contact with a patient must be cleaned before and after its use and before it is used on another patient".
* "All non-dedicated (shared) equipment and accessories that come into contact with a patient or a patient's environment must be cleaned by the staff that uses or transfers the item of clinical equipment between patients".

The hospital failed to fully implement its policy on clean patient care equipment. Refer to Findings 7-9, and Finding 10, observations of the patient care environment, including patient care equipment, and expired hospital cleaning products.

6.b. The P&P titled "Care and Handling of Soiled Instruments in the ED and Hospital" last approved "07/2023" was reviewed and reflected:
* Under "Procedure" was written "Place soiled instruments in stainless steel containers ... for dirty instruments located in the Emergency Department and Hospital's Nurse's Station hopper rooms. Instruments should then be sprayed with enzymatic cleaner completely with hinges open as soon as possible only in the hopper room and left in the container ... Soiled instruments should not leave the hopper room until being transported to Sterile Processing ... Sterile Processing Techs will check containers daily when working. All other days, when containers are full, Nursing staff will take full container to Central Sterile Processing and place ... in the large stainless steel rectangular container on the dirty counter to the Right of the sink, labeled 'Dirty Instruments and Containers'. Do not place in sink ... Items too large to be put in a metal dirty instrument container ... are to be placed in a plastic zip lock bag with a Biohazard label ... spray with enzymatic cleaner ... take to Central Sterile Processing and place in the large stainless steel rectangle container ..."

The P&P was unclear and not fully developed. For example, references, such as CDC Guidelines for sterilization and disinfection, were not listed and therefore it was unclear whether the policy was based on nationally recognized standards. Key stakeholders, such as the Infection Prevention Committee, were not listed to ensure that the procedures had been evaluated for any infection control risks. It was unclear on which enzymatic cleaner had been approved for use, how much spray to use, and manufacturer time limits on how long the instruments could remain "sprayed" with enzymatic cleaner was not described. It was unclear whether dirty instruments were picked up daily or whether the container was checked daily until full, and then transported to SPD. It was unclear whether the "plastic zip lock" bags were of sufficient durability, such as puncture resistant and leak proof, for use in transporting contaminated medical instruments.

6.c. The policy titled "Reprocessing of Surgical Instruments" dated as last approved "07/2023" was reviewed and reflected:
* Personal Protective Equipment listed included "Gloves, gowns, masks, face shields, goggles, head and shoe covers ... Fill clear gallon pitcher ... with cold tap water, pour into round metal basin and add ½ ounce of Ruhof Endozime AW Triple Plus per gallon ... Remove dirty instruments from large stainless steel rectangle container ... Rinse dirty instruments ... place in round metal basin ... fully submerged ...Soak at least 10 minutes ... With a clean disposable brush, scrub each instrument in the sink, be sure to take extra care with instruments with serrated teeth and all hinges."

The P&P was unclear and not fully developed. For example, references, such as the CDC, were not listed and therefore it was unclear whether the policy was based on nationally recognized standards. Key stakeholders, such as the Infection Prevention Committee, were not listed to ensure that the procedures had been evaluated for any infection control risks. It was unclear whether "gloves" were standard hospital gloves used in patient care areas or whether thicker, more durable gloves were required for the cleaning of medical instruments to avoid potential puncture wounds when handling sharp instruments. It was unclear whether "10 minutes" was the recommended soaking time for all instruments and whether that soaking time had been validated by the manufacturer to avoid rust or corrosion of the instruments.

6.d. The P&P titled "Autoclave Sterilization of Instruments" dated as last approved "07/2023" was reviewed and reflected:
* "Make a test pack ... Place test pouch in autoclave ... After the autoclave has shut off ... Check all pouches and packs to be sure that all steam indicators say 'SAFE'. If any say 'UNSAFE', the complete batch needs to be cleaned, packaged, and sterilized again starting with the procedure in the Reprocessing of Surgical Instruments Policy ... Take test pack to Hospital Lab for testing. Do not distribute sterile instruments at this time."

The P&P was unclear and not fully developed. For example, the policy did not contain any references, such as CDC Guidelines for sterilization and disinfection, and therefore it was unclear whether the policy was based on nationally recognized standards, such as monitoring and documenting all mechanical parameters for steam sterilization, the use of controls for validating the viability of the BI lot used in the sterilization process, or the optimum placement of the test pack. Key stakeholders, such as the Infection Prevention Committee and Laboratory, were not listed to ensure that the procedures had been evaluated for any infection control risks or adhered to nationally recognized standards. Generalized guidance was provided in the policy to verify a successful sterilization process, such as "Check ... to be sure ... indicators say 'SAFE' and did not include additional safety checks such as inspecting package integrity, visibly inspecting for damaged or soiled instruments, or whether the sterilizer failed to reach the proper time, temperature, or pressure. It was unclear whether the procedure for an "UNSAFE" batch included any further sterilizer inspections, testing, or maintenance procedures, including removal of the sterilizer from service in the event of a failed test.

6.e. The P&P titled "Reprocessing of Sterile Supplies" dated last approved "07/2023" was reviewed and reflected:
* "Scrub instruments with a soft end of brush from tip to handle, be sure items with grooves and rust showing are scrubbed with the wire end of the brush to be sure all debris and rust is removed."

The P&P was unclear and not fully developed. For example, the policy lacked references, such as CDC Guidelines for sterilization and disinfection, and therefore it was unclear whether the policy was based on nationally recognized standards, such as consideration of processing steps that may contribute to rusted or damaged instruments. Key stakeholders, such as the Infection Prevention Committee, were not listed to ensure that the procedures had been evaluated for any infection control risks. Cleaning, disinfection, and sterilization interventions were not mentioned as a possible contribution to the rusted instruments, such as soaking instruments longer than recommended by the manufacturer. It was unclear whether all rusted instruments could be successfully sterilized for use, or whether there was a degree of rust that would require that the rusted instrument be removed or replaced per the manufacturer's instructions for use.

6.f. A review of the policy titled "MasterCare Bath ... Cleaning" dated as last approved "07/2023"was reviewed and reflected:
* "Clean and disinfect bathtub after every bath with Disinfectant/Cleaner as follows ... "
* "Close door and rotate door open/close arm up. Rinse inside surfaces of tub with shower wand. Apply MasterCare disinfectant cleaner with disinfectant wand inside tub surfaces. Scrub with brush. Allow contact time of 10 minutes. Rinse with hot water and allow to dry. The tub may also be cleaned by soaking method. Mix 2 oz. solution for every gallon of water and allow tub to soak for 10 minutes. Rinse with hot water and allow to dry ... "
* "Note: MasterCare Disinfectant/Cleaner is a special non-abrasive cleaning and disinfecting solution that will not harm the Integrity Bath's fiberglass surface. MasterCare disinfectant/cleaner is the cleaning solution designed and recommended for use with the Integrity Bathing System. For proper use and safety follow the directions set forth by the manufacturer of the disinfectant/cleaner."

The policy was unclear and not fully developed. The policy did not describe the manufacturer's instructions for cleaning the internal components of the whirlpool tub where biofilm could form, nor did it list alternative disinfectants, such as the expired "Hydrogen Peroxide" disinfectant observed during the tour, refer to Finding 7, unit observation of multi-use whirlpool jetted tub. It was unclear whether the expired disinfectant had been validated by the manufacturer for disinfecting the whirlpool, including a validation of whether the disinfectant was caustic to internal parts, or whether the contact time should be increased for areas where biofilm could form, such as internal tubing and jetting system.

6.g. A user manual titled "Integrity Bath Model ... Installation Manuel" was identified by the DNS at the user manual for the "MasterCare Bath" was reviewed and reflected:
* "Check and Adjust Disinfectant Dispensing System ... Close the drain ... Open the dispensing cabinet on the head end of the bath ... Turn on the disinfectant ... that will dispense disinfectant through the jets ... Turn on the flush water ... run water through the disinfecting lines in the dispensing box ..."
* "CAUTION: DO NOT allow solutions or compounds containing chlorine, acid, basic ingredients or abrasives to come in contact with your MasterCare equipment. Failure to heed this caution could result in damage to the equipment ... "

6.h. The policy titled "Accu-Chek Blood Glucose Testing Policy" dated as last approved "07/2023" was reviewed and reflected:
* "Accu-Chek Inform II Controls ... Solutions out date 3 months from opening or the date printed on the strip vial label, whichever comes first. Date with new expiration date when new vial is opened."

7.a. During a tour of the SPD, with the DNS on 07/12/2023 at 1000, the following was observed:
* A bottle of "Surgi-Stain" and a bottle of "Endozime" located in a cabinet under the sink were observed to have expiration dates of 04/2022 and 6/2020, respectively.
* A large, stainless steel, rectangular container for depositing contaminated instruments where "Nursing Staff" were required to place transported contaminated instruments to SPD was not observed on the "dirty counter to the Right of the sink" as described in policy, refer to Finding 6.a., the process for care and handling of soiled instruments.

The DNS and the SP Tech confirmed the findings at the time of the observation regarding the expired products in the SPD. The SP Tech was asked to describe the sterilization process. The SP Tech stated that their normal procedure for soaking instruments was "30 minutes to an hour". When asked about the potential for rust or corrosion, the SP Tech was unaware of that this was a subject of concern. Additionally, when the SP Tech described the cleaning process, the SP Tech opened a drawer of brushes, which included a wire brush. When asked on what instruments the wire brush was used, the SP Tech replied, "I use it on the delicate instruments." The SP Tech described the process for documenting the load in the "Sterilization Log". A review of the "PMH Test Pack" documentation for 03/8/2023, 04/06/2023, 05/18/2023, 06/15/2023, 06/16/2023, and 06/21/2023 reflected the log included the date, pack or pouch, cycle length, temperature, chemical indicator used, test pack [with BI] used and operator initials. The log did not include documentation of the time the load was run, the sterilizer pressure, the lot number of the BI used in the test pack, or whether a control had been run from the same lot as the BI in the test pack to verify the viability of the BI. When asked what happens when a test pack fails, the SP Tech stated that the items get pulled and reprocessed. When asked whether the sterilizer gets inspected after a failed test pack, the SP Tech stated, "No." When asked how it was determined that a sterilization cycle had been successful, the SP Tech stated, "The strip changes color ... the lab also lets us know if the test pack was negative. We hold everything until the lab tells us [it was negative]." The hospital failed to adhere to nationally recognized standards and did not verify the viability of BI lots used in its sterilization process as evidenced by the lack of policy language or description, lack of BI control documentation and the SP Tech responses. Refer to Finding 6.c., the "Autoclave Sterilization of Instruments" policy.

7.b. During a tour of the Medical unit with the DNS, on 07/12/2023, beginning at 1200, the following was confirmed by the DNS at the time of the observation:
* A microwave and bath wipe warmer were located next to each other in a food prep area. The microwave in the food prep area was dirty and contained what looked like a piece of sausage.
* Bath wipes available for patient use were observed with an expiration date of 03/2023.
* In the multi-patient use shower room:
- Two bottles of aromatherapy beads were observed in a basket next to the whirlpool. There were no hospital-generated labels on either bottle with a patient name, drug name, strength, or description of the contents or whether the contents had been evaluated for use in patient care.
- A container of "Hydrogen Peroxide" disinfectant wipes was observed with an expiration date of 04/2023 on a counter next to the whirlpool bath.
- A bottle of "Hydrogen Peroxide" disinfectant with an expiration date of 04/14/2023 was observed on the side of the whirlpool tub with a plastic tube inserted into it. The tube was connected to the whirlpool tub as part of the cleaning and disinfecting system.
- A basket containing bandage scissors and a bottle of lotion were observed near the whirlpool bath. It was unclear whether the lotion was for multi-patient use and whether the scissors were clean.
* An in-patient room, previously used for endoscopic procedures, room 215, contained a mix of clean, dir

Based on interview and review of medical record documentation for 1 of 2 patients who expired at the CAH (Patient 28), it was determined that the CAH failed to notify the OPO of the patient's death to determine whether an organ donor request was indicated.

Findings included:

1. Review of the medical record for Patient 28 reflected that the patient expired at the CAH on 02/05/2023. There was no documentation in the medical record to reflect that the OPO was notified of the patient's death.

2. During interview with the CID on 07/12/2023 beginning at 1415 they confirmed there was no organ donor request for Patient 28.

Based on observations, interview, review of CAH scope of service documentation, and review of SA licensing documents and records it was determined that the CAH failed to ensure it was in compliance with applicable State laws and rules related to hospital licensing and changes in the building and physical environment.

Hospital licensing OAR 333-500-0045 requires that a hospital submit building plans and specifications to the SA, the State of Oregon hospital licensing authority, for review and approval prior to building construction, alterations or additions. Impacted areas may not operate until building plans review and licensing processes have been completed and approval for the project(s) is received from the SA FPS Unit. The CAH failed to comply as follows:
* The CAH converted an inpatient room into Dexa and US imaging services, without FPS Unit plans review and approval.

Findings include:

1.a. An organizational chart that depicted the CAH's inpatient and outpatient departments and services dated "Rev. 5/19/2023" reflected that the CAH provided "Radiology" services.

1.b. Observations in the CAH's Imaging services area on 07/12/2023 beginning at 1105 included Room 204 that had a sign under the room number that read "Emergency Room Overflow." Room 204 was observed to contain numerous imaging equipment and supply items. During the tour, the radiology sonographer stated that Dexa and US services were provided in that room. The radiology sonographer stated that the room was previously an inpatient room.

1.c. During interview on 07/13/2023 at 1020, the CCO provided the following information regarding Dexa and US imaging services:
* Room 204, the space where Dexa and US imaging services are currently provided was previously an inpatient room.
* The CAH began providing Dexa and US imaging services in Room 204 in "2016" and they could not find any documentation that the CAH had notified the SA FPS Unit of this change.

1.d. In an email from the SA FPS Unit Manager on 07/13/2023 at 0950 they confirmed that the hospital had not submitted plans for approval of the change of use of Room 204 to a space for imaging services. The CAH had not obtained SA review and approval prior to changing the use of the previously approved inpatient room.

1.e. During interview on 07/13/2023 at 1745 at the exit conference, the COO stated they did not think they had a policy that ensured the CAH initiated SA FPS Unit review before making changes to a space in the CAH.



44104

Based on interview and review of the CAH's lists of services furnished under contract, arrangement or agreement it was determined that the current list of all services furnished under contract, arrangement or agreement was not clear or complete.
* The list was not clear and did not include all such services.
* The list did not include clear and complete descriptions of the nature and scope of the services provided, to include at a minimum: The service(s) being offered; The individual(s) or entity providing the service(s); Whether the services are offered on- or off-site; Whether there is any limit on the volume or frequency of the services provided; and When the service(s) are available.

Findings included:

1.a. An undated and untitled document with two columns for "Service Agreement" and "Scope/Description" was reviewed. Under "Service Agreement" the document contained a list of 23 entities' or organizations' names. Under "Scope/Description" it contained a brief corresponding description.

1.b. The "Service Agreement" list did not reflect all services provided under contract, arrangement or agreement, nor did it clearly identify the name of the entity or organization. For example:

* A "Contractor Evaluation List - 2022" included the following entities or organizations that were not on the "Service Agreement" list provided and for which no "Scope/Description" was reflected.
- "Imaging Center of Idaho"
- "MRI Mobile"
- "Mobile MRI, 2nd agreement"
- "MRI Mobile IMC."
- "Emergency Dental TX"
- "Kadlec PICC"
- "Rocky Mountain PT"
- "Hospice DME"
- "ECG and Holter GSHCS"
- "SBHC"

* On the "Service Agreement" list "Mobile MRI" was listed. On the "Contractor Evaluation List - 2022" there were three entries for mobile MRI services. It was not clear how many entities or organizations the CAH had MRI agreements with, nor the name(s) of the entity or entities providing the service.

* During tour of the ED on 07/11/2023, staff present stated that the hospital had contracts or agreements with:
- "Prowaste" for sharps/biohazard disposal.
- "Stryker" for biomedical preventive maintenance of ED beds and the LUCAS device used for mechanical chest compressions.
- A DME company for "mini concentrators."

* During interview with the CEO on 07/13/2023 beginning at 1125 they confirmed that other contracted services provided were not included on the "Service Agreement" list and included:
- QMHP
- SLP

* In an email received on 07/13/2023 at 1528 from the CEO the following contract was provided that was not included on the "Service Agreement" list:
- DHS, SDSD, SWING BED INTERGOVERNMENTAL AGREEMENT dated "9-25-95".

1.c. For all 23 contracts/agreements listed on the "Services Agreements" list the "Scope/Description" of the services provided did not include the elements identified in the deficient practice statement above. For example:

* For "American Red Cross" the "Scope/Description" was identified as only "Blood products and services."

* For "Central Oregon Radiology Associates" the "Scope/Description" was identified as only "Radiologists reading group."

* For "Mobile MRI" the "Scope/Description" was identified as only "MRI diagnostic imaging." Nor was it clear whether "Mobile MRI" was the name of the contracted MRI company.

* For "Murray's Drugs" the "Scope/Description" was identified as only "Pharmaceutical services."

* In addition, there was no "Scope/Description" reflected for the entities/organizations identified on the "Contractor Evaluation List - 2022."

2. During interview with the CEO on 07/13/2023 beginning at 1125 they confirmed that the "Service Agreement" list did not include all services provided under contract, arrangement or agreement and that it did not contain the required descriptions of the nature and scope of services provided.