Statement of Deficiencies and Plan of Correction 8/10/2020

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
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NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
300 MAIN STREET
CENTRAL MAINE MEDICAL CENTER
LEWISTON, ME 04240
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
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A 000 INITIAL COMMENTS A 000
Federal Complaint #34618

On-Site Survey: 7/29/2020, 7/30/2020, and
8/6/2020
Off-Site Survey: 7/31/2020, and 8/3/2020 through
8/5/2020
Immediate Jeopardy (IJ) at:

- §482.12 Condition of Participation: Governing
Body;
- §482.42 Condition of Participation: Infection
Prevention and Control and Antibiotic
Stewardship Programs;
- §482.42(a) Standard A-0749: Infection
prevention and control program organization and
policies; and
- §482.42(a)(3) Standard A-0750: Infection
prevention and control program organization and
policies.
- IJ template given to provider on 8/6/2020 at 4:00

PM
- Initial removal plan submitted by the hospital on
8/7/2020
- Revised removal plan was reviewed and
approved by the State Agency on 8/10/2020
- IJ abated as confirmed by on-site visit on
8/10/2020
Conditional Level Deficiencies Identified:

- §482.12 Condition of Participation: Governing
Body also known as A-043; and
- §482.42 Condition of Participation: Infection
Stewardship Programs also known as A-0747.
A complaint investigation was conducted at
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YOPJ11 Facility ID: ME200024 If continuation sheet Page 1 of 32
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A 000 Continued From page 1 A 000

Central Maine Medical Center (CMMC), an Acute
Care Hospital, to evaluate compliance with 42
Code of Federal Regulations, §482.42 Condition
of Participation: Infection Prevention and Control
and Antibiotic Stewardship Programs.
This survey determined that the hospital was not

in substantial compliance with 42 Code of Federal
Regulations §482.12 Condition of Participation:
Governing Body and
§482.42 Condition of Participation: Infection
Stewardship Programs. The identified
non-compliance constituted a determination of IJ,
beginning on 6/25/2020.
Based on document reviews, observations, and

interviews, the hospital failed to implement
strategies, including screening of visitors,
patients, and employees, to prevent and control
the transmission of COVID-19, to ensure
employees wore a facemask within the hospital,
and to ensure a clean and sanitary environment
in the Intensive Care Unit (ICU). It was
determined that these failures constituted an
immediate jeopardy situation. Immediate jeopardy
is defined as a situation in which a recipient of
care has suffered or is likely to suffer serious
injury, harm, impairment or death as a result of a
provider's noncompliance with one or more health
and safety requirements. See A-0749 and A-0750
for details.
The hospital was provided written notification (IJ

template) on 8/6/2020 at 4:00 PM.
The hospital submitted a removal plan that was

approved by the State Agency on 8/10/2020. This
removal plan indicated the following:
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a. Incident command meets three times a week

and the President of CMMC (as an authorized
offer of CMMC) and all key clinical and
operational stakeholders, including infection
prevention participates. In addition, a daily
huddle, including the President of CMMC, is
conducted to bring forth in-house safety
concerns. The CMMC Hospital President will
receive updates on compliance with the below
plan on through the incident command structure.
In addition, these updates will be brought to the
CMMC Board of Directors on a monthly basis.
b. Screening: Visitors and Patients:
The following entry points would be available to

visitors and patients: 60 High Street (during
normal business hours); 12 High Street (during
normal business hours); the Emergency
Department (ED) main entrance; and the
Hammond Street entrance (which is limited to
radiology oncology patients).
The ED main entrance would be staffed with

screening personnel.
Temperatures of all visitors and patients would be

taken.
To augment current screening processes, manual

logs would be implemented at all entrances to
document the following for patients: date; name;
symptom check, temperature, and pass/no pass
of screening criteria.
As part of the screening criteria the following

questions would be asked: "Are you currently
experiencing symptoms of an upper respiratory
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infection (productive cough, shortness of breath,
fever, sore throat)?"; :Have you lost your sense of
taste or smell?"; "Are you experiencing
generalized symptoms such as achiness,
headaches, fatigue, with or without
vomiting/diarrhea?"; and "In the last 14 days,
have you had contact with someone with
confirmed or suspected of COVID-19, or a person
that is exhibiting signs of respiratory illness?"
All unmanned entry points would be closed to

badge access to prevent unauthorized entry by
visitors and patients.
c. Screening: Employees
The following entry points would be available to

employees: the 60 High Street entrance between
6:00 AM and 6:59 PM and the ED entrance
between 7:00 PM and 5:59 AM.
A manual log of all employees screened will be

implemented at all entrances to document the
following: date; name; symptom check; fever; and
pass/no pass of screening criteria.
As part of the screening criteria the following

questions would be asked: "Are you currently
experiencing symptoms of an upper respiratory
infection (productive cough, shortness of breath,
fever, sore throat)?"; :Have you lost your sense of
taste or smell?"; "Are you experiencing
generalized symptoms such as achiness,
headaches, fatigue, with or without
vomiting/diarrhea?"; and "In the last 14 days,
have you had contact with someone with
confirmed or suspected of COVID-19, or a person
that is exhibiting signs of respiratory illness?"
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All unmanned employee entry points would be
closed to badge access.
d. Personal Protective Equipment (PPE) Usage:

Masks
Screeners will enforce masking upon entry and

employees would not be permitted beyond the
screener area without a mask properly donned.
e. Clean and Sanitary Environment:
Routine Cleaning: Specially designated staff will

be trained to perform routine cleaning of the high
touch and horizontal services, empty trash, soiled
linens, bathroom, dry and damp mop floors in
COVID 19 positive patient rooms following
standard work documents and competency check
lists.
Specially designated staff will begin a schedule of

regular cleaning in all COVID 19 positive patient
rooms.
Overflowing trash cans containing PPE: Specially

designated staff will empty the PPE trash
receptacle as dictated by routine cleaning
standard work in all COVID 19 positive patient
rooms.
Specially designated departments will maintain a

daily cleaning checklist to document routine
cleaning of COVID 19 positive patient rooms.
f. Infection Control Surveillance:
Daily rounds will be performed and documented

by Infection Prevention team members Monday
through Friday and by the Nursing Supervisor on
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Saturday and Sunday to observe recommended
COVID 19 prevention strategies including: active
screening of patients, visitors, and staff; masking
upon entry; routine cleaning of COVID 19 positive
rooms; and appropriate donning, doffing, and
disposal of PPE.
Security would perform routine checks of all

access points to ensure that badge access was
disabled.
On 8/10/2020, surveyors verified that the

hospital's plan to remove the IJ was implemented
and was effective. The surveyors determined the
abatement of the IJ by interviewing the
Regulatory Compliance Coordinator, the Critical
Care Manager, the Chief Medical Officer (CMO)
and an ICU Certified Nursing Assistant Technician
regarding the process of ensuring screening
employees, visitors and patients, and maintaining
a clean environment on the ICU Unit; reviewing
the completed screening documentation for 33
randomly selected employees from five different
departments who worked since 8/9/2020; and
observing employees maintaining compliance
with facial coverings and limiting points of entry
for employees. In addition, the CMO confirmed
the process for surveillance and leadership
involvement to ensure the Governing Body is
monitoring processes.
A 043 GOVERNING BODY A 043
CFR(s): 482.12
There must be an effective governing body that is

legally responsible for the conduct of the hospital.
If a hospital does not have an organized
governing body, the persons legally responsible
for the conduct of the hospital must carry out the
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functions specified in this part that pertain to the
governing body ...
This CONDITION is not met as evidenced by:

interviews, it was determined that the Condition of
Participation for Governing Body was not met as
evidenced by the Governing Body's failure to
provide oversight of the hospital as evidenced by
the failure to implement all possible strategies to
prevent and control the transmission of
COVID-19; to ensure that the prevention and
control program included surveillance; to ensure
the maintenance of a clean and sanitary
environment; and to ensure documention of
infection control rounds. It was determined that
the hospital's failures constituted an immediate
jeopardy situation. Immediate jeopardy is defined
as a situation in which a recipient of care has
suffered or is likely to suffer serious injury, harm,
impairment or death as a result of a provider's
noncompliance with one or more health and
safety requirements.
Findings:
The Governing Body has failed to provide

oversight of the hospital as evidenced by the
following:
1. Condition: §482.42 Condition of Participation:

Infection Prevention and Control and Antibiotic
Stewardship Programs also known as A-0747 -
Participation for Infection Prevention and Control
and Antibiotic Stewardship Programs was not met
as evidenced by the hospital's failure to
implement all possible strategies to prevent and
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control the transmission of COVID-19; to ensure
that the prevention and control program included
surveillance; to ensure the maintenance of a
clean and sanitary environment; and to ensure
documention of infection control rounds. It was
determined that the hospital's failure to implement
all possible strategies to prevent and control the
transmission of COVID-19, to conduct
surveillance for infection control, and to provide a
clean and sanitary environment constituted an
immediate jeopardy situation. Immediate jeopardy
is defined as a situation in which a recipient of
care has suffered or is likely to suffer serious
injury, harm, impairment or death as a result of a
provider's noncompliance with one or more health
and safety requirements. See A-0747 for details.
2. Standard: §482.42(a)(2) Infection Control

Program also known as A-0749 - Based on
document reviews, observations, and interviews,
the hospital failed to implement all possible
strategies to prevent and control the transmission
of COVID-19. It was determined that the
hospital's failure to implement all possible
strategies constituted an immediate jeopardy
situation. Immediate jeopardy is defined as a
situation in which a recipient of care has suffered
or is likely to suffer serious injury, harm,
safety requirements. See A-0749 for details.

Surveillance, Prevention also known as A-0750 -
interviews, the hospital has failed to ensure that
the prevention and control program included
surveillance to ensure all strategies prevent and
control the transmission of COVID-19 were
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implemented and failed to ensure the
maintenance of a clean and sanitary environment
in the Intensive Care Unit. It was determined that
the hospital's failure to ensure surveillance and a
clean environment constituted an immediate
4. Standard: §482.42(c)(1) Leadership

Responsibilities (Governing Body) also known as
A-0770 - Based on document reviews,
observations, and interviews, the hospital's
Governing Body failed to ensure that the hospital
had systems in place to ensure all possible
of COVID-19 were implemented and monitored
and failed to ensure systems were in place to
maintain a clean and sanitary patient
environment. See A-0770 for details.

responsibilities (Infection Preventionist) also
known as A-0772 - Based on document reviews,
Infection Preventionist failed to implement
infection control strategies to prevent and control
the transmission of COVID-19 and to monitor the
strategies (surveillance) as per the United States
Centers for Disease Control and Prevention
guidance. See A-0772 for details.
6. Standard: §482.42(c)(2)(ii) Infection Control

Professional Documentation also known as
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Infection Preventionist failed to ensure
documention of infection control rounds. See
A-0773 for details.
Please see A-0000 Initial Comments for details

related to the IJ template, removal plan, and
abatement of the IJ.
The cumulative effect of these deficient practices

resulted in noncompliance with this Condition of
Participation.
A 747 INFECTION PREVENTION CONTROL ABX A 747
STEWARDSHIP
CFR(s): 482.42
The hospital must have active hospital-wide

programs for the surveillance, prevention, and
control of HAIs and other infectious diseases, and
for the optimization of antibiotic use through
stewardship. The programs must demonstrate
adherence to nationally recognized infection
prevention and control guidelines, as well as to
best practices for improving antibiotic use where
applicable, and for reducing the development and
transmission of HAIs and antibiotic resistant
organisms. Infection prevention and control
problems and antibiotic use issues identified in
the programs must be addressed in collaboration
with the hospital-wide quality assessment and
performance improvement (QAPI) program.
This CONDITION is not met as evidenced by:
Participation for Infection Prevention and Control
and Antibiotic Stewardship Programs was not met
as evidenced by the hospital's failure to
implement all possible strategies to prevent and
control the transmission of COVID-19; to ensure
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surveillance; to ensure the maintenance of a
clean and sanitary environment; and to ensure
documention of infection control rounds. It was
determined that the hospital's failures constituted
an immediate jeopardy situation. Immediate
jeopardy is defined as a situation in which a
recipient of care has suffered or is likely to suffer
serious injury, harm, impairment or death as a
result of a provider's noncompliance with one or
more health and safety requirements.
Findings:

Program also known as A-0749 - Based on
document reviews, observations, and interviews,
the hospital failed to implement all possible
of COVID-19. It was determined that the
hospital's failure to implement all possible

Surveillance, Prevention also known as A-0750 -
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Responsibilities (Governing Body) also known as
Governing Body failed to ensure that the hospital
had systems in place to ensure all possible
of COVID-19 were implemented and monitored
and failed to ensure systems were in place to
environment. See A-0770 for details.

responsibilities (Infection Preventionist) also
known as A-0772 - Based on document reviews,
Infection Preventionist failed to implement
infection control strategies to prevent and control
the transmission of COVID-19 and to monitor the
strategies (surveillance) as per the United States
Centers for Disease Control and Prevention
guidance. See A-0772 for details.
5. Standard: §482.42(c)(2)(ii) Infection Control

Professional Documentation also known as
Infection Preventionist failed to ensure
documention of infection control rounds. See
A-0773 for details.
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The cumulative effect of this deficient practice

resulted in noncompliance with this Condition of
Participation.
A 749 INFECTION CONTROL PROGRAM A 749
CFR(s): 482.42(a)(2)
The hospital infection prevention and control

program, as documented in its policies and
procedures, employs methods for preventing and
controlling the transmission of infections within
the hospital and between the hospital and other
institutions and settings;
This STANDARD is not met as evidenced by:
interviews, the hospital failed to implement all
possible strategies to prevent and control the
transmission of COVID-19. It was determined that
the hospital's failure constituted an immediate
Findings:
On 7/29/2020, the Division of Licensing and

Certification was made aware of an outbreak of
COVID-19. An on-site investigation was initiated.
On 7/29/2020 at 9:35 AM, the System Director of

Infection Prevention stated, the hospital had four
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(4) patients who were COVID-19 positive, one (1)
patient who was an person under investigation,
and an outbreak of twelve (12) staff members
who were COVID-19 positive.
This survey identified the following:
1. The United States Centers for Disease Control

and Prevention (US CDC)'s "Interim Infection
Prevention and Control Recommendation for
Healthcare Personnel During the Coronavirus
Disease 2019 (COVID-19) Pandemic", updated
7/15/2020, indicated all facilities "screen everyone
(patients, HCP [Health Care Personnel], visitors)
entering the healthcare facility for symptoms
consistent with COVID-19 or exposure to others
with SARS-CoV-2 infection and ensure they are
practicing source control" and "actively take their
temperature and document absence of
symptoms consistent with COVID-19. Fever is
either measured temperature 100.0°F or
subjective fever".
On 7/29/2020 at 9:25 AM and 9:30 AM, surveyors

were screened at the Main Entrance (60 High St.)
of the hospital. Surveyors were asked about
COVID-19 symptoms but the temperature of the
surveyors was not taken upon entrance to the
hospital, per the CDC screening
recommendations.
On 7/29/2020 at 9:25 AM, surveyors observed

visitors being screened at the Main Entrance (60
High St.) of the hospital. The visitors were asked
about COVID-19 symptoms but the temperature
of the visitors was not taken upon entrance to the
recommendations.
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On 7/29/2020 at 9:25 AM, 9:30 AM, and 11:00
AM, surveyors observed visitors being screened
at the Main Entrance (60 High St.) of the hospital.
The visitors were asked about COVID-19
symptoms but the temperature of the visitors was
not taken upon entrance to the hospital, per the
CDC screening recommendations.
On 7/29/2020 at 10:53 AM, a surveyor observed

visitors being screened at the 12 High Street of
the hospital. The visitors were asked about
visitors was not taken upon entrance to the
recommendations.
On 7/29/2020 at 12:30 PM, a surveyor observed

an employee enter at the Main Entrance (60 High
Street). The employee was not screened upon
entrance to the hospital, per the CDC screening
recommendations.
On 7/30/2020 at 6:00 AM, surveyors were

screened at the Main Entrance of the hospital
surveyors were not asked about COVID-19
symptoms but the temperature of the surveyors
was taken upon entrance to the hospital, per the

employees enter the Main Entrance (60 High
Street) of the hospital. Employees were not
screened upon entrance to the hospital, per the
On 7/30/2020 at 6:05 AM and 6:10 AM, surveyors

observed employees enter the Main Entrance (60
High Street) of the hospital. Employees were not
screened upon entrance to the hospital, per the
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On 7/30/2020 at 6:20 AM, surveyors were

screened at the 12 High Street entrance.
Surveyors were asked about COVID-19
symptoms but the temperature of the surveyors
was not taken upon entrance to the hospital, per
the CDC screening recommendations.

patients being screened at the 12 High Street
entrance. The patients were asked about
patients was not taken upon entrance to the
recommendations.
On 7/30/2020 at 6:20 AM, surveyors observed an

employee enter at the 12 High Street entrance.
The employee was not screened upon entrance
to the hospital, per the CDC screening
recommendations.
On 7/30/2020 at 6:35 AM, surveyors entered the

Emergency Department (ED) entrance and
observed staff also entering through this
entrance. No screener was present; therefore, no
screening was conducted at this entrance per the

several employees walking towards another
possible point of entry. Between 6:43 AM and
7:00 AM, surveyors observed multiple staff,
including the System Director of Quality Services,
enter through the designated "Employee
Entrance", which was badge accessed only. Staff
allowed surveyors to enter through this door
without confirming who they were. There was no
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screening at this entrance into the hospital, per
the CDC screening recommendations.
On 7/30/2020 at 7:01 AM, surveyors again

entered the Emergency Department (ED)
entrance. Again, no screener was present;
therefore, no screening was conducted at this
entrance per the CDC screening
recommendations. The surveyors observed that
anyone entering this entrance could access the
hospital without being screened.
On 7/30/2020 at 11:00 AM, a surveyor observed

visitors being screened at the Main Entrance (60
High St.) of the hospital. The visitors were asked
about COVID-19 symptoms but the temperature
of the visitors was not taken upon entrance to the
recommendations.
Surveyors requested any written

policy/protocol/procedure in relation to screening.
An email, dated 6/10/2020, was given to surveyor
which stated "We are refining our entry process
for team members after receiving valuable
feedback on our process. Reflecting new policies
at many other health systems, we will no longer
be performing temperature checks as of Friday,
June 12th".
An email, dated 6/24/2020, was provided to

surveyors. This email stated, "Temperatures are
no longer utilized as a screening tool. Team
members will not be screened for symptoms
...patients and allowed visitors will be questioned
about symptoms, provided with masks if they do
not have them; and will go directly to their
appointment ....you [team members] will be
required to complete a one-time online screening
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tool. The process for team members has been
updated. Please remember to enter the premises
only through authorized entrances when you
report to work. We have opened up additional
doors ...the following entrances are now open via
badge access only: Doctors Parking Level,
Employee Entrance by the ED, Linen Doors on
Lower Level Near Parking Garage and Delivery
Door into the MOB".
On 7/29/2020 at 11:15 AM, the Critical Care

Manager stated, "We have just started, I think it
was the 25th of July, screening staff when they
get to the unit, we don't take temperatures ...just
a subjective screening for fever. We don't screen
lab employees".
On 7/29/2020 at 11:45 AM, a Phlebotomist

stated, "We used to get screened before coming
into the hospital, but now we wear a mask and if
we don't have any of the symptoms, we are good
to work. It is an honor system for screening in the
morning. There is no screening to come on to this
unit or for the lab".
On 7/29/2020, at 2:30 PM, the Regulatory

Compliance Coordinator stated the following:
- "Before 6/25/2020, employees were screened at

the two main entrances."
- "After that date, we had the employees sign an

attestation form one time, electronically, and then
the only thing they do daily when they come in is
get a new mask, if they don't have one, and
complete hand hygiene".
- "There are three entrances that staff use to

come to the hospital which is 12 High Street
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(outpatient services), 60 High Street (main
entrance) and the ED Entrance, but I don't think
many people come through the ED unless they
work there".
On 7/30/2020 at 8:05 AM, surveyors asked the

hospital's Leadership representatives for
clarification of the new screening process for
staff. A Leadership representative indicated that
the new process began on 7/27/2020, staff would
be screened on the unit before they start their
shift, and this would be documented.
On 7/30/202 at 8:17 AM, the Interim Nurse

Leader of the ED stated, "We are screening staff
on the unit prior to them getting their assignment
and documenting every shift".
On 7/30/2020 at 8:35 AM, the ED staff

assignment schedule and the screening
documentation of the ED staff for 7/30/2020 was
reviewed. The review revealed there was no
evidence that three (3) of eight (8) staff, who were
working, had been screened. The lack of
documented screening was confirmed by the
Interim Nurse Leader at the time of the review.
On 7/30/2020 at 10:10 AM, the T-3, inpatient unit,

staff schedule and the screening documentation
was requested. The staff assignment schedule
for 7/30/2020 was provided which indicated eight
(8) staff to be working at 10:10 AM. The
screening documentation was not provided. The
T-3 Unit Charge Nurse stated, "I did it, but just
haven't typed it into the computer yet". When
asked how she knew the answers to the
screening questions, she stated, "I just remember
it" and she confirmed she had not taken notes at
the time of screening at the start of the shift.
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DEFICIENCY)
On 7/30/2020 at 10:20 AM, Certified Nursing

Assistant (CNA) #1, who was working on T-3,
stated, "The nurse doesn't ask each individual in
the huddle about symptoms, it's just a loose
question about symptoms".
On 7/30/2020 at 10:25 AM, CNA #2., who was

working on T-3, stated "We get screened as a
group in huddle".
On 7/30/2020 at 12:55 PM, Environmental

Services (EVS) employee #3 , "They don't screen
us anymore, they used to screen us, and take our
temperature".
2. The US CDC's "Interim Infection Prevention

and Control Recommendation for Healthcare
Personnel During the Coronavirus Disease 2019
(COVID-19) Pandemic", updated 7/15/2020,
indicated all facilities should "limit and monitor
points of entry to the facility."
On 7/29/2020, at 2:30 PM, the Regulatory

Compliance Coordinator stated "There are three
entrances that staff use to come to the hospital
which is 12 High Street, 60 High Street (Main
Entrance) and the ED Entrance.
An email, dated 6/24/2020, was provided to

surveyors. This email stated, "We have opened
up additional doors ...the following entrances are
now open via badge access only: Doctors
Parking Level, Employee Entrance by the ED,
Linen Doors on Lower Level Near Parking
Garage and Delivery Door into the MOB [Medical
Office Building]".
On 7/30/2020 at 6:35 AM, surveyors entered the

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ED entrance and observed staff also entering
through this entrance. There was no monitoring
of this entrance, per the CDC screening
recommendations.

several employees walking towards another
possible point of entry. Between 6:43 AM and
7:00 AM, surveyors observed multiple staff,
including the System Director of Quality Services,
enter through the designated "Employee
Entrance", which was badge accessed only. Staff
allowed surveyors to enter through this door
without confirming who they were. There was no
monitoring of this entrance, per the CDC
screening recommendations.
On 7/30/2020 at 7:01 AM, surveyors again

entered the Emergency Department (ED)
entrance. Again, this entrance was not monitored,
per the CDC screening recommendations.
On 7/30/2020 at 10:45 AM, the System Director

of Infection Prevention stated, that Incident
Command restricted entrances for employees
until a few weeks ago when they opened up all
employee entrances as before with badge access
only.

indicated fever is a measured temperature at
100.0 degrees Fahrenheit (F).
On 6/29/2020, surveyors requested hospital

policies/protocols/procedures related to
COVID-19. One of the documents received was
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the "Outpatient Assessment and management for
Pregnant Women with Suspected or Confirmed
Novel Coronavirus (COVID - 19)" which states
when assessing the patient look for a fever of
100.4 degrees F.
On 7/30/2020 at 6:36 AM, a sign in the ED

entrance was observed that instructed the reader
to tell the Triage Nurse if you have an elevated
temperature of 100.4 degrees F.

of Infection Prevention was interviewed and was
asked about the temperature of 100.4 degrees F
on the sign. She stated that she is following CDC
and National Health Safety Network guidelines in
relation to the temperature. She provided a
document titled "Definitions of Symptoms of
Reportable Illness", dated 6/30/2017, which
indicated the "CDC considers a person to have a
fever when he or she has a measure temperature
of 100.4 F or greater".
The System Director of Infection Prevention was

not aware of the current CDC guidance for fever.

indicated facilities should "post visual alerts (e.g.:
signs, posters) at the entrance and in strategic
places (e.g., waiting areas, elevators, cafeterias)
to provide instructions (in appropriate languages)
about wearing a cloth face covering or facemask
for source control and how and when to perform
hand hygiene."
On 7/29/2020 at 9:25 AM and 9:30 AM and on

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7/30/2020 at 6:20 AM, 6:35 AM and 7:01 AM,
surveyors observed signs related to COVID-19 at
the 12 High Street, 60 High Street, and the ED
entrances. However, there was no evidence of
any other signs placed strategically within the
hospital.

indicated health care personnel should wear a
facemask at all times while they are in the
healthcare facility.
On 7/30/2020 at 6:36 AM, one (1) employee was

observed entering through the ED entrance
without a facemask and proceeded into the
hospital without putting a facemask on.
On 7/30/2020 at 6:43 AM, a sign was observed

on the Employee Entrance door that stated, "To
utilize these doors you must have a mask before
entering".
On 7/30/2020 at 6:43 AM, two (2) employees

were observed entering through the Employee
Entrance and proceeded up the stairs without a
facemask.

A 750 INFECTION CONTROL SURVEILLANCE, A 750
PREVENTION
CFR(s): 482.42(a)(3)
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Findings:
1. Based on document reviews, observations,

and interviews, the hospital failed to implement all
transmission of COVID-19. See A-0749 for
details.
2. On 7/29/2020 between 11:15 AM and 11:45

AM in the Intensive Care Unit, where four (4)
confirmed COVID-19 patients and one (1) patient
under investigation were being treated, the
following was observed in the presence of the
Critical Care Manager:
- Visible dirt buildup and many visible dried

splatter stains were on the hallway floor, by
Rooms #428, #429, and #430
- A used glove was on the bottom of a cart in the

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hallway
- An opened box was on the hallway floor
- Intravenous (IV) poles, with IV machines

attached, were located outside three (3) ICU
Rooms (#428, #429, and #430). The tubing from
the machine was touching the floor in two (2) of
the rooms (Room #428 and #429).
- The floor in Room #428 had brown dried liquid

areas, visible dirt, and trash (e.g.: alcohol pads,
IV caps, IV bag stoppers, and straw wrappers).
- The floor in Room #429 had several brown dried

liquid areas, visible dirt, and trash (e.g.: alcohol
pads and IV caps).
On 7/29/2020 at 11:20 AM, the Critical Care

Manager stated, the following:
- The housekeeping staff do not go into any

patient room that the patient is positive or under
investigation for COVID-19;
- The Nurses clean the bedside table and counter

tops daily but do not clean the floors;
- The patient in Room #428 has been in the room

for ten (10) days and the floor probably had not
been clean; and
- The hallway gets mopped twice a week.
On 7/29/2020 at 12:50 PM, Environmental

Services (EVS) employee #1 stated, "Patient
rooms cleaned daily if occupied, but EVS does
not enter patient rooms with COVID-19".
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of Infection Prevention was interviewed in relation
to infection control surveillance. She stated,
"Infection Preventionist Staff make daily rounds, I
am in Administration, to monitor/enforce
compliance and report back to the Unit Managers
for employee follow-up. There is no
documentation for the daily rounds".
On 7/30/2020 at 4:00 p.m., an EVS Employee #2

who stated, all precaution rooms are cleaned
every day except COVID-19 rooms which are
done after discharge.
On 7/30/2020 between 4:10 PM and 4:30 PM, in

the Intensive Care unit, where three (3) confirmed
COVID-19 patients and one (1) patient under
investigation were being treated, surveyors
observed the following:
- Visible dirt buildup and many visible dried

splatter stains on the hallway floor by Rooms
#428, #429, and #430;
- An overflowing trash can in the hall between

ICU Room #429 and ICU Room 430;
- A dirty towel was on the floor inside Room #430;
- A used IV bag was on the floor outside Room

#429;
- IV poles, with IV machines attached, were

located outside two (2) ICU Rooms (#429, and
#430). The tubing from the machine was touching
the floor in one (1) of the room (Room #429);
- Brown dried liquid areas, visible dirt, and trash

(e.g.: alcohol pads, IV caps, IV bag stoppers, and
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straw wrappers) on the floor in Room #428.
- The floor in Room #429 had several brown

dried liquid areas, a wet area under the foot of the
bed, visible dirt, and trash (e.g.: alcohol pads and
IV caps).
On 7/30/2020 at 4:35 PM during the exit

conference with hospital leadership, the System
Director of Infection Prevention stated, "We don't
place environmental workers in the COVID-19
positive patient rooms in accordance with CDC
Guidelines". When asked if she had made
observations in the ICU, she stated, "No, I have
not seen it".

A 770 LEADERSHIP RESPONSIBILITIES A 770
CFR(s): 482.42(c)(1)(i)
Standard: Leadership responsibilities
(1) The governing body must ensure all of the

following:
(i) Systems are in place and operational for the

tracking of all infection surveillance, prevention,
and control, and antibiotic use activities, in order
to demonstrate the implementation, success, and
sustainability of such activities.
interviews, the hospital's Governing Body failed to
ensure that the hospital had systems in place to
ensure all possible strategies to prevent and
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implemented and monitored and failed to ensure
systems were in place to maintain a clean and
sanitary patient environment.
Finding:
The Governing Body has failed to ensure that the

hospital failed to ensure that the hospital had
systems in place to ensure all possible strategies
to prevent and control the transmission of
COVID-19 were implemented and monitored and
failed to ensure systems were in place to
environment. This was evidenced by the
following:

and interviews, the hospital failed to implement all
transmission of COVID-19. It was determined that
the hospital's failure to implement all possible
safety requirements. Please see A-0749 for
details.

and interviews, the hospital has failed to ensure
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safety requirements. Please see A-0750 for
details.
A 772 IC PROFESSIONAL RESPONSIBILITIES A 772
POLICIES
CFR(s): 482.42(c)(2)(i)
Standard: Leadership responsibilities
(2) The infection preventionist(s)/infection control

professional(s) is responsible for:
(i) The development and implementation of
hospital-wide infection surveillance, prevention,
and control policies and procedures that adhere
to nationally recognized guidelines.
interviews, the hospital's Infection Preventionist
failed to implement infection control strategies to
COVID-19 and to monitor the strategies
(surveillance) as per the United States Centers
for Disease Control and Prevention guidance.
Finding:

COVID-19 at the hospital. An on-site investigation
was initiated.
Based on observations on 7/29/2020 and

7/30/2020, surveyors determined the hospital
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failed to implement all possible strategies to
COVID-19 and that the hospital failed to ensure a
clean and sanitary environment. Please see
A-0749 and A-0750 for details.

patient who was a person under investigation,

of Infection Prevention was interviewed regarding
employee screening upon entrance to the
hospital and the temperature of 100.4 degrees
Fahrenheit (F) on signs observed in the hospital.
She stated, that Incident Command restricted
entrances for employees until a few weeks ago
when they opened up all employee entrances as
before with badge access only. When asked
about the temperature of 100.4 degrees Fé on
the sign, she stated that she is following CDC and
National Health Safety Network guidelines in
relation to the temperature. She provided a
document titled "Definitions of Symptoms of
Reportable Illness", dated 6/30/2017, which
indicated the "CDC considers a person to have a
fever when he or she has a measure temperature
of 100.4 F or greater". The System Director of
Infection Prevention was not aware of the current
CDC guidance for fever which is 100.0 degrees
F.
On 7/30/2020 at 4:35 PM during the exit

conference with hospital leadership, surveyors
discussed observations of an unclean
environment in the Intensive Care Unit (ICU). The
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System Director of Infection Prevention stated,
"We don't place environmental workers in the
COVID-19 positive patient rooms in accordance
with CDC Guidelines". When asked if she had
made observations in the ICU, she stated, "No, I
have not seen it".
A 773 IC PROFESSIONAL DOCUMENTATION A 773
CFR(s): 482.42(c)(2)(ii)
[The infection preventionist(s)/infection control

professional(s) is responsible for:]
(ii) All documentation, written or electronic, of the

infection prevention and control program and its
surveillance, prevention, and control activities.
interviews, the hospital's Infection Preventionist
failed to ensure documention of infection control
rounds.
Finding:

COVID-19 at the hospital. An on-site investigation
was initiated.
Based on observations on 7/29/2020 and

7/30/2020, surveyors determined the hospital
failed to implement all possible strategies to
COVID-19 and that the hospital failed to ensure a
clean and sanitary environment. Please see
A-0749 and A-0750 for details.

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patient who was a person under investigation,

of Infection Prevention was interviewed in relation
to infection control surveillance. She stated,
"Infection Preventionist Staff make daily rounds, I
am in Administration, to monitor/enforce
compliance and report back to the Unit Managers
for employee follow-up. There is no
documentation for the daily rounds".

Statement of Deficiencies and Plan of Correction 8/10/2020

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Statement of Deficiencies and Plan of Correction 8/10/2020

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PRINTED: 08/20/2020

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

A 000 INITIAL COMMENTS A 000

Federal Complaint #34618

Immediate Jeopardy (IJ) at:

- IJ template given to provider on 8/6/2020 at 4:00

Conditional Level Deficiencies Identified:

A complaint investigation was conducted at

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

A 000 Continued From page 1 A 000

This survey determined that the hospital was not

Based on document reviews, observations, and

The hospital was provided written notification (IJ

The hospital submitted a removal plan that was

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

A 000 Continued From page 2 A 000

a. Incident command meets three times a week

b. Screening: Visitors and Patients:

The following entry points would be available to

The ED main entrance would be staffed with

Temperatures of all visitors and patients would be

To augment current screening processes, manual

As part of the screening criteria the following

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

A 000 Continued From page 3 A 000

All unmanned entry points would be closed to

The following entry points would be available to

A manual log of all employees screened will be

As part of the screening criteria the following

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

A 000 Continued From page 4 A 000

d. Personal Protective Equipment (PPE) Usage:

Screeners will enforce masking upon entry and

e. Clean and Sanitary Environment:

Routine Cleaning: Specially designated staff will

Specially designated staff will begin a schedule of

Overflowing trash cans containing PPE: Specially

Specially designated departments will maintain a

f. Infection Control Surveillance:

Daily rounds will be performed and documented

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

A 000 Continued From page 5 A 000

Security would perform routine checks of all

On 8/10/2020, surveyors verified that the

There must be an effective governing body that is

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

A 043 Continued From page 6 A 043

This CONDITION is not met as evidenced by:

The Governing Body has failed to provide

1. Condition: §482.42 Condition of Participation:

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

A 043 Continued From page 7 A 043

2. Standard: §482.42(a)(2) Infection Control

3. Standard: §482.42(a)(3) Infection Control

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

A 043 Continued From page 8 A 043

4. Standard: §482.42(c)(1) Leadership

5. Standard: §482.42(c)(2) Leadership

6. Standard: §482.42(c)(2)(ii) Infection Control

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

A 043 Continued From page 9 A 043