Valley View Medical Center

“Procedures for Tracking of Staff and Patients CFR(s): §403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility’s] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF’s, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF’s, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees’ on-duty and sheltered patients in the hospice’s care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients. This Standard is not met as evidenced by: 45167 Based on review of facility documentation and interview, it has been determined the facility failed to develop and maintain a system to track the location of on-duty staff and sheltered patients in the hospital’s care during an emergency, as well as the location of any on-duty staff and/or sheltered patients that have been relocated as a result of an emergency. This deficient practice can result in an increased likelihood of death or injury to staff and/or patients if needed emergency care cannot be provided when injured staff and/or patients cannot be found. Findings include: Facility document titled, “Emergency Operations Plan” indicated: “...On-Duty Staff...The organization has a system to track the location of on-duty staff during an emergency. The organization will keep current records indicating when staff are assigned to what duties and when they are reassigned....” In an interview conducted on December 2, 2025, Employee #6 was not able to provide a centralized record of all staff and their assigned duties and was not familiar with how a list like this would be generated in the event of an emergency, in a powered event or an event with no electricity.”

“Arrangement with Other Facilities CFR(s): §403.748(b)(7), §418.113(b)(5), §441.184(b)(7), §460.84(b)(8), §482.15(b)(7), §483.73(b)(7), §483.475(b)(7), §485.625(b)(7), §485.920(b)(6), §494.62(b)(6). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] *[For Hospices at §418.113(b), PRFTs at §441.184,(b) Hospitals at §482.15(b), and LTC Facilities at §483.73(b):] Policies and procedures. (7) [or (5)] The development of arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For PACE at §460.84(b), ICF/IIDs at §483.475(b), CAHs at §486.625(b), CMHCs at §485.920(b) and ESRD Facilities at §494.62(b):] Policies and procedures. (7) [or (6), (8)] The development of arrangements with other [facilities] [or] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For RNHCIs at §403.748(b):] Policies and procedures. (7) The development of arrangements with other RNHCIs and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of non-medical services to RNHCI patients. This Standard is not met as evidenced by: 45167 Based on review of facility documentation and interview, it was determined the facility failed to develop arrangements with hospitals and other providers to receive patients in the event of limited and/or cessation of operations in the event of an emergency. This deficient practice can result in a failure of continuity of care, leading to death or poor outcomes for patients. Findings include: Facility document titled, “...Emergency Operations Plan....” indicated: “...Sharing of resources...The regional hospital group has developed an MAA [Mutual Aid Agreement] or MOU [Memorandum of Understanding] that outlines the processes for sharing resources with other healthcare organizations within the region. The Form IV...identifies the resources that are available for sharing...In anticipation of potential facility damage, the organization has established a plan to utilize an alternate care site for patient care...The details for these alternate care sites are documented in the Alternate Care Sites document....” Facility policy titled, “EM.12.02.09.1-3 Management of Supplies Policy” indicated: “...A Mutual Aid Agreement has been developed for items that would exceed par levels or expire, such as additional antibiotics, vaccines, and PPE...The MOU will reference the expedited items that may be in need during a large-scale disaster. These items would either expire or exceed normal inventory during a large-scale disaster. The MOU information will include...Contact information fo who the agreement is with....” Facility policy titled, “EM.12.01.01.8 Alternate Care Site Plan....” indicated: “...Valley View Medical Center will collaborate with authorized representatives from each prospective site to establish a mutual aid agreement for the use of designated spaces for patient care services...In the selection of alternate sites, priority will be given to other hospitals within the community. Secondary preference will be given to other healthcare facilities....” Copies of all MOUs (Memorandums of Understanding) and MAAs executed regarding the sharing of supplies and alternate care sites were requested but none could be provided. In an interview conducted on December 2, 2025, Employees #6 and #4 explained that there was an informal agreement with Havasu Regional Medical Center regarding the sharing of supplies and the ability to transfer patients there in the event of an emergency; however, no written agreements had ever been executed.”

“Names and Contact Information CFR(s): §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: 45167 Based on facility documentation and interview, it has been determined the facility failed to develop and implement within the emergency preparedness Communication Plan, names and contact information for the following: staff, patients’ physicians, and volunteers. This deficient practice could delay information or services during an emergency. Findings include: Facility document titled, “...Emergency Operations Plan....” indicated: “...Names and contact information are maintained of the following...Staff...Physicians...Other hospitals and CAHs...Volunteers...Entities providing services under agreements....” In addition to this referenced document, a large binder of materials was provided. The names and contact information of staff, physicians, and volunteers could not be found. In an interview conducted on December 2, 2025, Employee #6 confirmed that this information was not contained within the communication plan and related materials, nor could a list of these names and contact information easily and rapidly be generated.”

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 45167 Based on review of facility documentation and interview, it has been determined the facility failed to develop a training program that was facility and plan specific. This deficient practice may lead to untrained staff in an emergency situation and may result in harm to the patients during an emergency if staff are not aware of what is required by them to do, during an emergency situation. Findings include: Facility document titled, “...Emergency Operations Plan....” indicated: “...To keep hospital staff informed of emergency planning and response information, response updates will be published in hospital newsletters and presented at employee orientationand safety fairs....” Documentation of training of staff at hire and annually on the contents of the Emergency Operations Plan was requested. Documentation was provided of a HealthStream module titled, “Emergency Preparedness” and documentation that this module was reviewed by all staff at hire and annually. The curriculum for this module was requested and provided. The module provided general information about emergency preparedness plans. For example, “...The plan should include strategies to handle emergency events identified by the risk assessment...The plan needs to identify the types of services the facility could provide...The facility is required to develop an emergency preparedness communication plan...The plan should outline how to coordinate care within the facility....” In an interview conducted on December 2, Employee #6 confirmed that this was the only training provided to the staff on the emergency preparedness plan and that no additional specific training on the facility’s emergency preparedness plan was provided.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 45167 Based on review of facility documentation and interview, it has been determined the facility failed to ensure that a full-scale drill was conducted at least every two years followed by either a subsequent full-scale drill the following year, or else a community-based drill, functional drill, mock disaster drill, tabletop drill or real-life emergency that required activation of the facility emergency preparedness plan and the documentation of the curriculum, after-action report and documentation of a sufficient number of staff attendance retained. This deficient practice can result in the facility having a plan that is not actionable or practicable in a real-life disaster event, leading to increased likelihood of staff and patient injury or death. Findings include: Documentation of emergency preparedness drills conducted in calendar years 2025, 2024, and 2023. Drills conducted in 2025, including a real-life emergency was documented in 2025 in lieu of a drill, were acceptable in content and format. The emergency preparedness drills requested for calendar year 2024 could not be provided. In an interview conducted on December 2, 2025, Employee #6 explained that the drills had been conducted, but a prior employee had retained the documentation and when the employee left Valley View Medical Center, it was discovered that the documentation was lost. On July 19, 2023, an emergency drill was conducted that involved a scenario of a van rollover with 7 (seven) injured parties. Although the after-action report and attendance were deemed sufficient, in an interview conducted on December 2, 2025, Employee #6 acknowledged that this was not sufficient as a scenario to meet the standard as an emergency preparedness drill that would activate the facility’s emergency preparedness plan.”

“Gas and Vacuum Piped Systems - Categories CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Categories Medical gas, medical air, surgical vacuum, WAGD, and supply air systems are designated: o Category 1 - Systems in which failure is likely to cause major injury or death. o Category 2 - Systems in which failure is likely to cause minor injury. o Category 3 - Systems in which failure is not likely to cause injury, but can cause discomfort. Deep sedation and general anesthesia are not to be administered using a Category 3 medical gas system. 5.1.1.1, 5.2.1, 5.3.1.1, 5.3.1.5 (NFPA 99) This Standard is not met as evidenced by: 45167 Based on observation while on tour, review of facility documentation, and interviews, it has been determined the facility has failed to ensure that the medical gas system was properly installed, maintained, and utilized according to the category of system (Category 1). This deficient practice can result in increased risk of fire or injury to staff and/or patients from a medical gas accident and/or incident. NFPA 99, 2011 edition, Section 1.3.2.3 An existing system that is not in strict compliance with the provisions of this code shall be permitted to be continued in use, unless the authority having jurisdiction has determined that such use constitutes a distinct hazard to life. NFPA 99, Standard for Health Care Facilities, 2005 Edition, Chapter 5, Gas and Vacuum Systems, Section 5.1.3.7.3 If WAGD is joined to vacuum piping, it shall be connected a minimum distance of 1.5 m (5 ft.) from any vacuum inlet. NFPA 99, Standard for Health Care Facilities, 2005 Edition, Chapter 5, Section 5.1.3.7.6 The WAGD pumps shall exhaust in compliance with 5.1.3.6.7. 5.1.3.6.7.2 indicated: The exhaust shall be located as follows: ...(2) At least 3.05 m (10 ft) from any door, window, air intake, or other opening in building. (3) At a level different from air intakes. NFPA 99, Standard for Health Care Facilities, 2005 Edition, Chapter 5, Section 5.1.3.5.13.1 The medical air compressors shall draw their air from a source of clean air located where no source of contamination is anticipated from engine exhausts, fuel storage vents, medical-surgical vacuum discharges, particulate matter, or odor of any type. NFPA 99, Standard for Health Care Facilities, 2005 Edition, Chapter 5, Section 5.1.3.5.13.2. Compressor intake. The compressor air intake shall be located outdoors above roof level, at a minimum distance of 3.05 m (10 ft.) from any door, window, exhaust, other intake, or opening in the building, and a minimum distance of 6.1 m (20 ft.) above the ground. NFPA 99, Standard for Health Care Facilities, 2005 Edition, Chapter 5, Section 5.1.4.1. Gas and Vacuum Shutoff Valves. Shutoff valves shall be provided to isolate sections or portions of the piped distribution system for maintenance, repair, or for planned future expansion need, and to facilitate periodic testing. NFPA 99, Standard for Health Care Facilities, 2005 Edition, Chapter 5, Section 5.1.4.8.7. A zone valve shall be located immediately outside each vital life-support, critical care, and anesthetizing location, in each medical gas and/or vacuum line, and located so as to be readily accessible in an emergency. NFPA 99, Standard for Health Care Facilities, 2005 Edition, Chapter 5, Section 5.1.5.1. Each station outlet/inlet for medical gases or vacuum shall be gas-specific, whether the outlet/inlet is threaded, or is a noninterchangeable quick-coupler. NFPA 99, Standard for Health Care Facilities, 2005 Edition, Chapter 5, Section 5.1.5.16 WAGD networks shall provide a WAGD inlet in all locations where nitrous oxide or halogenated gas is intended to be administered. Findings include: Interviews were conducted with Employee #3 on December 1, 2025, with Employee #2 on December 2, 2025, and with Employee #4 on December 3, 2025, which confirmed that the medical gas system was installed when the hospital was constructed in 2005, with the exception of the cath lab and IMT (intermediate care unit) which were constructed in 2008, and the Rehabilitation unit, Med/Surg 2, Peds unit, and an addition to the emergency room, all of which were added in 2011. Employees #4 and #7 confirmed that, outside of the operating rooms, where general anesthesia could be expected to be used, moderate sedation only was used in Procedure Rooms 1 & 2, where colonoscopies were the typical procedure that was performed, and in the cath lab. When asked about Patient #1, who was administered general anesthesia in the cath lab on August 11, 2025, both Employee #4 and Employee #7 stated that they believed this was the only time general anesthesia was administered in the cath lab. Employee #7 provided records from 2023, 2024 and 2025 indicating that moderate sedation was utilized in the cath lab with the exception of Patient #1 who was administered general anesthesia. During observation conducted while on tour on December 1, 2, & 3, Compliance Officer observed WAGD (waste anesthetic gas disposal) inlets in operating rooms only (Compliance Officer specifically toured Operating Rooms 1, 2, 3, & 4 and observed WAGD inlets in all four operating rooms). Employee #2 removed ceiling tiles so Compliance Officer could view the piping above the celing in Operating Rooms #1 and #4. Compliance Officer observed the WAGD piping appeared to be joined to the medical-vaccum piping less than 5 (five) feet from the nearest medical-vacuum inlet. Compliance Officer did not observe zone valves or any other type of shutoff valves for WAGD in the operating room area. Compliance Officer conducted this tour with multiple members of administrative staff, including Employees #1, #2, #4, & #6, and mentioned not seeing valves for WAGD but was not directed to any valves. Compliance Officer toured Procedure Rooms 1, 2, Cath Lab, the Emergency Room, ICU (Intensive Care Unit) and PACU (post-anesthesia care unit). There were no inlets for nitrous oxide or for WAGD and no valves for either. However, “Operating Room Logs” for Cath Lab from 2023, 2024, and 2025 indicated moderate sedation and, in at least once instance, general sedation, were provided. It cannot be determined from the information provided what type of moderate sedation was administered. In an interview conducted with Employee #4 on December 2, 2025, Employee #4 indicated that the general sedation provided to Patient #1 on August 11, 2025 in the cath lab was not intended; however, “...Quick Notes....” dated July 14, 2025 Arizona Department of Health Services indicated, “...Given [patient’s] combative movements with vigorous movements of his legs, his PCI [Percutaneous Coronary Intervention] procedure will need to be completed with anesthesia....” During observation conducted while on tour on December 1, 2, & 3, Compliance Officer requested to be shown where the WAGD exhausted and where the medical air intake was located. Employees #2 and 3 led Compliance Officer to a rooftop area round the back of the hospital and indicated the WAGD exhaust to be a down-turned pipe located above a window on the corner of the rooftop (Compliance Officer did not take measurements and therefore could not say if the end of the exhaust was more than 10 feet away from the window). Compliance Officer was shown a similarly downturned pipe on the other end of the roofline located directly next to an item of equipment that Employee #3 identified as an air handler unit. Compliance Officer pointed out that the WAGD exhaust and the medical air compressor intake appeared to be installed at the same level as one another and expressed concern about the proximity of the medical air compressor intake to the air handler unit. Employee #3 acknowledged in an interview conducted on December 3, 2025 that the WAGD exhaust and medical air intake were installed at the same level and that the air handler unit was in close proximity to the medical air compressor intake but did not believe the air handler unit would cause an issue with particulate matter regarding the medical air compressor intake.”

“Gas and Vacuum Piped Systems - Warning System CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Warning Systems All master, area, and local alarm systems used for medical gas and vacuum systems comply with appropriate Category warning system requirements, as applicable. 5.1.9, 5.2.9, 5.3.6.2.2 (NFPA 99) This Standard is not met as evidenced by: 45167 Based on observation while on tour, review of facility documentation and interviews, it has been determined the facility failed to ensure that required alarms were provided for the WAGD (waste anesthetic gas disposal) system. This deficient practice can result in staff being unaware when the WAGD system is malfunctioning or underperforming. Findings include: NFPA 99, 2011 edition, Section 5.1.9.2 indicated, “A master alarm system shall be provided to monitor the operation and condition of the source of supply, the reserve source (if any), and the pressure in the main lines of each medical gas and vacuum supply system.” A.5.1.9.2 See Table A.5.1.9.2...5.1.9.2.4 Master alarm panels for medical gas and vacuum systems shall each include the following signals...(11) WAGD low alarm when the WAGD vacuum level or flow is below effective operating limits....” NFPA 99, 2011 edition, Section 5.1.9.3 indicated, “Area alarm panels shall be provided to monitor all medical gas, medical surgical vacuum, and piped WAGD systems supplying the following...A.5.1.9.3. (1) Anesthetizing locations where moderate sedation, deep sedation, or general anesthesia is administered (2) Critical care areas...TABLE A.5.1.9.3 Requirements for Category I Area Alarms...A.5.1.9.3(2) Examples of critical care areas include post-anesthesia recovery, intensive care units, and emergency departments.” NFPA 99, 2011 edition, Section 1.3.2.3 indicated, “An existing system that is not in strict compliance with the provisions of this code shall be permitted to be continued in use, unless the authority having jurisdiction has determined that such use constitutes a distinct hazard to life.” NFPA 99, 2005 edition, Section 5.1.9.2.4 Master alarm panels for medical gas and vacuum systems shall each include the following signals: ...(11) A WAGD low alarm when the WAGD vacuum level or flow is below effective operating limits; NFPA 99, 2005 edition, Section 5.1.9.3. Area alarm panels shall be provided to monitor all medical gas, medical-surgical vacuum, and piped WAGD systems supplying anesthetizing locations, and other life support and critical areas (e.g. post-anesthesia recovery, intensive care units, emergency departments, etc.). Observation while on tour conducted on December 1, 2, & 3 indicated that a WAGD system was piped into the operating rooms at Valley View Medical Center which was confirmed by architectural drawings provided by Employee #2 that were executed by Gould Turner Group, P.C. on March 5, 2004. The WAGD system was not an independent producer, but rather was tied into the medical vacuum. During observation conducted on tour on December 1, 2, & 3, the master alarm panel was observed, but there were no alarms for WAGD which was confirmed by Employee #3 in an interview conducted on December 3, 2025. Area alarms were observed, but there were no alarms for WAGD in the operating room areas or elsewhere in the hospital. In an interview conducted on December 2, 2025 while on tour, Employee #2 confirmed there were no area alarms for WAGD and Employee #3 confirmed there was no WAGD alarms on the master alarm panel.”

“Gas and Vacuum Piped Systems - Central Supply CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Central Supply System Operations Adaptors or conversion fittings are prohibited. Cylinders are handled in accordance with 11.6.2. Only cylinders, reusable shipping containers, and their accessories are stored in rooms containing central supply systems or cylinders. No flammable materials are stored with cylinders. Cryogenic liquid storage units intended to supply the facility are not used to transfill. Cylinders are kept away from sources of heat. Valve protection caps are secured in place, if supplied, unless cylinder is in use. Cylinders are not stored in tightly closed spaces. Cylinders in use and storage are prevented from exceeding 130 degrees Fahrenheit, and nitrous oxide and carbon dioxide cylinders are prevented from reaching temperatures lower than manufacture recommendations or 20 degrees Fahrenheit. Full or empty cylinders, when not connected, are stored in locations complying with 5.1.3.3.2 through 5.1.3.3.3, and are not stored in enclosures containing motor-driven machinery, unless for instrument air reserve headers. 5.1.3.2, 5.1.3.3.17, 5.1.3.3.1.8, 5.1.3.3.4, 5.2.3.2, 5.2.3.3, 5.3.6.20.4, 5.6.20.5, 5.3.6.20.7, 5.3.6.20.8, 5.3.6.20.9 (NFPA 99) This Standard is not met as evidenced by: 45167 Based on observation while on tour and interview, it has been determined the facility failed to ensure that positive-pressure gases are properly and securely stored. This deficient practice can result in a fire, leading to potential harm to patients or staff. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. NFPA 99 Section 5.1.3.1 Subsection A.5.1.3.3.2(7) They shall be provided with racks, chains, or other fastenings to secure all cylinders from falling, whether connected, unconnected, full, or empty. Findings include: During observation on tour in the medical gas central supply room conducted on December 3, 2025, Compliance Officer observed 6 (6) large yellow cylinders under a sign that indicated “FULL” that were chained together with one chain only, and two large gray plus one large navy cylinder, also under the “FULL” sign chained together with one chain only. In an interview conducted on December 3, 2025, Employees #1, 2 #3 acknowledged the deficient practice.”

“Gas and Vacuum Piped Systems - Information an CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Information and Warning Signs Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (Table 5.1.11), and operating pressure if other than standard. Labels are at intervals not more than 20 feet, are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency. 5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99) This Standard is not met as evidenced by: 45167 Based on observation while on tour, facility documentation, and interview, it has been determined the facility failed to appropriately label medical gas piping. This deficient practice can result in confusion or error. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. NFPA 99 2012 Edition Chapter 5, Section 5.1.11.1 Piping shall be labeled by stenciling or adhesive markers that identify the patient medical gas, the support gas, or the vacuum system and include the following...Name of the gas or vacuum system or the chemical symbol per Table 5.1.11...Gas or vacuum system color code per Table 5.1.11...the operating pressure...Pipe labels shall be located as follows...At intervals of not more than 6.1m (20ft).... During observation on tour conducted on December 2, 2025, Employee #2 removed ceiling tiles in Operating Rooms 1 and 4 so that medical gas piping could be observed above the ceiling. In the ceiling of Operating Room 1, medical gas pipes could be seen traveling vertically above the ceiling that were labeled with adhesive markers wrapped around the piping. The adhesive marking appeared old and degraded and was difficult, and in some instances, impossible, to read, such as on the vertical WAGD pipe. In the ceiling of Operating Room 4, medical gas pipes could be observed traveling vertically above the ceiling that were labeled with adhesive markers wrapped around the piping. The adhesive marking appeared old and degraded and was difficult, and in some instances, impossible, to read. The horizontal piping in Operating Room 4 was more visible and additional labeling could be observed on the horizontal piping that appeared newer and therefore easier to read; however, some vertical piping, including the piping designated as WAGD piping on architectural plans confirmed by architectural drawings provided by Employee #2 that were executed by Gould Turner Group, P.C. on March 5, 2004, did not have legible labeling. In an interview conducted on December 2, 2025, Employee #2 confirmed the labeling of the gas piping as it was maintained on December 2, 2025.”

“Gas Equipment - Qualifications and Training CFR(s): NFPA 101 Gas Equipment - Qualifications and Training of Personnel Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment. 11.5.2.1 (NFPA 99) This Standard is not met as evidenced by: 45167 Based on review of facility documentation and interview, it was determined the facility failed to ensure that continuing education in safety guidelines and usage of maintenance and operation of medical gas equipment was provided. This deficient practice can lead to errors in the use of medical gas, resulting in injury to patients and/or staff. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. NFPA 99 2012 Edition Chapter 11 Section 11.5.2.1. Personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be trained on the risks associated with their handling and use. A.11.5.2.1.1. “Personnel” typically includes physicians, nurses, nursing assistants, respiratory therapists, engineers, technicians and others. 11.5.2.1.2. Health care facilities shall provide programs of continuing education for their personnel. 11.5.2.1.3. Continuing education programs shall include periodic review of safety guidelines and usage requirements for medical gases and their cylinders. Findings include: Documentation of education regarding the handling of medical gases at hire and annually was requested. A HealthStream curriculum was provided that is completed at hire and annually by all staff which included content regarding Hazard Communication and Workplace Safety Basics. Although this content did contain general information that was applicable to the safe handling of hazardous material, including gases, there was very little content regarding the safe handling of medical gases and cylinders containing medical gas. Additionally, content was provided regarding “Environment of Care” rounds which are conducted on the treatment floors monthly with staff. This included some educational slides regarding the handling and storage of oxygen; however, no other medical gas was addressed or mentioned in the Environment of Care content, and although attendance was collected at hire and annually for the HealthStream training, the attendance for Environment of Care rounds was more informal. In an exit interview conducted on December 3, 2025, administrative staff present acknowledged the deficient practice.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 43788 Based on review of documents and staff interviews, it was determined the hospital failed to follow policies and procedures regarding: 1. Ensuring a medical screening examination was provided to a pregnant woman complaining of abdominal pain and vomiting. (Patient #22) 2. Ensuring proper documentation was present in the medical record for a pregnant woman that left against medical advice. (Patient #7) 3. Ensuring a pregnant woman was offered all possible treatment and stabilization prior to discharge. (Patient #18) Findings include: 1. Policy titled, “EMTALA- Medical Screening and Treatment of Emergency Medical Conditions”, revealed: “...To ensure that individuals coming to a Valley View Medical Center’s Dedicated Emergency Department seeking assessment or treatment for a medical condition, or coming to Hospital Property requesting (or obviously requiring) treatment for an Emergency Medical Condition receive an appropriate Medical Screening Examination....DEFINITIONS: I. Emergency Medical Condition means: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy ...L. Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists or a woman is in labor. Such screening must be done within the facility ’ s capability and available personnel, including on-call physicians ...The Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient ’ s needs and must continue until the patient is either stabilized or appropriately transferred ...Policy: Any individual who comes to the Hospital Property of Premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination performed by a physician or other Qualified Medical Personnel to determine whether or not an Emergency Medical Condition exists ...D. Special Circumstances: Withdrawal of Request for Examination: ...2. If a patient leaves the Hospital without notifying Hospital personnel, this should be documented. The documentation must reflect that the patient had been at the Hospital and the time the patient was discovered to have left the premises ....” Review of the hospital Emergency Department Log revealed Patient #22 arrived at the Emergency Department on 06/02/2024 at 12:48 with a presenting complaint of 13 weeks pregnant with abdominal pain and vomiting. Further review revealed Patient #22 was triaged at 13:11. Further review of the ED log review revealed Patient #22 was discharged on 06/02/2024 at 17:21 with disposition labeled Eloped: LWOT (left without treatment). Further review of the hospital Emergency Department Log for June 2024 revealed Patient #22 length of stay in the ED was 4 hours and 33 minutes without being evaluated by a medical provider for an Emergency Medical Condition. Employee #3 confirmed on 11/20/2024 that Patient #22 left the ED before a MSE was performed. 2. Policy titled, “EMTALA- Medical Screening and Treatment of Emergency Medical Conditions”, revealed: “...To ensure that individuals coming to a Valley View Medical Center’s Dedicated Emergency Department seeking assessment or treatment for a medical condition, or coming to Hospital Property requesting (or obviously requiring) treatment for an Emergency Medical Condition receive an appropriate Medical Screening Examination...If an Emergency Medical Condition is determined to exist, such individuals are offered stabilizing treatment with the Hospital’s capabilities and/or are transferred if appropriate, all without regard to the patient’s insurance coverage or ability to pay...D. Special Circumstances: Withdrawal of Request for Examination: 1. If a patient withdraws his or her request for examination or treatment, an appropriately trained individual from the emergency department staff should discuss the medical issues related to a voluntary withdrawal. In the discussion, the emergency department staff member should: a. Offer the patient further medical examination and treatment as may be required to identify and stabilize and/or Emergency Medical Condition; b. Inform the patient of the benefits or the examination and/or treatment, and of the risks of withdrawal prior to receiving the examinations and/or treatment; and c. Use reasonable efforts to get the patient to sign a form indicating that the patient has refused the recommended examination and/or treatment. The form should contain a description of risks discussed and of the examination and/or treatment that was refused ...2. If a patient leaves the Hospital without notifying Hospital personnel, this should be documented. The documentation must reflect that the patient had been at the Hospital and the time the patient was discovered to have left the premises ....” Review of Patient #7 Emergency Department medical record physician documentation dated 03/21/2024 revealed: “...walk in with complaints of Abdominal pain 7 weeks preganant ...Differential diagnosis: Ectopic Pregnancy, Threatened abortion, Appendicitis, Colitis ...ED course: 0645 discussed again with patient and boyfriend the concerns regarding ectopic elevated white blood count, etc. She says she wants to leave but is convinced to stay ...0715 laying on the gurney to obtain the ultrasound she suddenly jumped up and says I am leaving, the ultrasound tech tries to reassure to stay but she refuses she grabs her clothes and runs to the exit. One of the nurses was able to take her IV out. Patient and boyfriend at this point are aware of the concerns regarding intra abdominal and intrauterine pathology and emergency. They understand the risks including miscarriage and death of the mother and baby. They have been encouraged to return at any time ...Disposition Summary: 03/21/2024 0725 Left Against Medical Advice ....” Further review of Patient #7 Emergency Department medical record revealed no evidence of a completed Leaving Against Medical Advice form signed by the patient nor any documentation that staff attempted to get Patient #7 to complete the required form indicating the patient was refusing further care and treatment. Employee #3 confirmed on 11/20/2024 that Patient #7 left against medical advice and the required AMA form was not present in the patient ’ s medical record. 3. Policy titled, “EMTALA- Medical Screening and Treatment of Emergency Medical Conditions”, revealed: “...To ensure that individuals coming to a Valley View Medical Center’s Dedicated Emergency Department seeking assessment or treatment for a medical condition, or coming to Hospital Property requesting (or obviously requiring) treatment for an Emergency Medical Condition receive an appropriate Medical Screening Examination...If an Emergency Medical Condition is determined to exist, such individuals are offered stabilizing treatment with the Hospital’s capabilities and/or are transferred if appropriate, all without regard to the patient’s insurance coverage or ability to pay...T. Stabilized with respect to an Emergency Medical Condition means that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from the facility or in the case of a woman in labor, that the woman delivered the child and the placenta. A patient deemed stabilized if the treating physician of the individual with an Emergency Medical Condition has been resolved ...U. To Stabilize means, with respect to an Emergency Medical Condition to either provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of individual form a facility or, in the case of a woman in labor, that the woman has delivered the child and the placenta ...V. Stable for Discharge: A patient is considered stable for discharge, when within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient or later as an inpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions ...Policy: Any individual who comes to the Hospital Property of Premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination performed by a physician or other Qualified Medical Personnel to determine whether or not an Emergency Medical Condition exists. If an Emergency Medical Condition is found to exist, the Hospital will (without regard for the patient ’ s insurance coverage or ability to pay) provide: (a) stabilizing treatment within the capabilities of the Hospital and its staff (including on-call physicians and diagnostic services)....” Review of Patient #18 Emergency Department provider note dated 05/18/2024 revealed: “....presents to the emergency department after leakage of fluid and some bleeding ...She is 16 weeks gestation with a Singleton pregnancy ...In the emergency department, fluid was essentially 0 ...Prognosis is very grim however, I did talk to the patient about antibiotic prophylaxis and her and her husband did decide to be admitted to labor and delivery for IV antibiotics ...ED Course: repeat ultrasound was performed at 3:50 p.m. there was no additional amniotic fluid, however cardiac tones were visualized on this effort at about 150-160 discussed in person with the OBGYN physician at the bedside who also visualized the ultrasound and agreed to admit the patient for oligohydramnios and observation in L and D ...Final Impression:Potentially rule out: IUFD ...Disposition Summary: Hospitalization ordered....” Further review of Patient #18 Emergency Department medical record revealed no documented evidence that alternative treatments for stabilization were discussed or provided for Patient #18 Employee #3 confirmed on 11/20/2024, that Patient #18 was made Observation status with obstetrics and was given antibiotics.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 43788 Based on review of documents and staff interviews, it was determined the hospital failed to provide an MSE to a pregnant woman who presented to the Emergency Department with a complaint of abdominal pain (Patient #22). The patient waited approximately 4.5 hours before leaving the hospital without being seen by a medical provider. Findings include: Policy titled, “EMTALA- Medical Screening and Treatment of Emergency Medical Conditions”, revealed: “...To ensure that individuals coming to a Valley View Medical Center’s Dedicated Emergency Department seeking assessment or treatment for a medical condition, or coming to Hospital Property requesting (or obviously requiring) treatment for an Emergency Medical Condition receive an appropriate Medical Screening Examination....DEFINITIONS: I. Emergency Medical Condition means: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy ...L. Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists or a woman is in labor. Such screening must be done within the facility ’ s capability and available personnel, including on-call physicians ...The Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient ’ s needs and must continue until the patient is either stabilized or appropriately transferred ...Policy: Any individual who comes to the Hospital Property of Premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination performed by a physician or other Qualified Medical Personnel to determine whether or not an Emergency Medical Condition exists ...D. Special Circumstances: Withdrawal of Request for Examination: ...2. If a patient leaves the Hospital without notifying Hospital personnel, this should be documented. The documentation must reflect that the patient had been at the Hospital and the time the patient was discovered to have left the premises ....” Review of the hospital Emergency Department Log revealed Patient #22 arrived at the Emergency Department on 06/02/2024 at 12:48 with a presenting complaint of 13 weeks pregnant with abdominal pain and vomiting. Further review revealed Patient #22 was triaged at 13:11. Further review of the ED log review revealed Patient #22 was discharged on 06/02/2024 at 17:21 with disposition labeled Eloped: LWOT (left without treatment). Further review of the hospital Emergency Department Log for June 2024 revealed Patient #22 length of stay in the ED was 4 hours and 33 minutes without being evaluated by a medical provider for an Emergency Medical Condition. Review of Patient #22 Emergency Department medical record dated 06/02/2024 revealed the following ED course: 12:51 Patient arrived in ED. 12:51 Patient moved to waiting 13:11 Triage completed 13:12 No physician assisted procedures were completed 13:13 Patient moved to ED waiting. Further review of Patient #22 ED medical record dated 06/02/2024 revealed Patient #22 was triaged with an ESI of 3. Further review of Patient #22 ED medical record dated 06/02/2024 revealed the following: Outcome: 16:45 Eloped prior to medical screening exam. 17:20 Patient left the ED. 17:21 Patient left the ED. Further review of Patient #22 ED medical record revealed a Physician Documentation note dated 06/02/2024 which revealed: “...Disposition Summary: 06/02/2024 17:20 Eloped, Disposition: Left Prior to Medical Screening Exam; Reason: Unknown reason ....” Employee # 3 confirmed on 11/20/2024 that Patient #22 left the Emergency Department before a Medical Screening Examination was completed.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 43788 Based on review of documents and staff interview, it was determined the hospital failed to ensure: 1. proper documentation was present in the medical record for a pregnant woman that left against medical advice. (Patient #7) 2. a pregnant woman was offered all possible treatment and stabilization prior to discharge. (Patient #18) Findings include: 1. Policy titled, “EMTALA- Medical Screening and Treatment of Emergency Medical Conditions”, revealed: “...To ensure that individuals coming to a Valley View Medical Center’s Dedicated Emergency Department seeking assessment or treatment for a medical condition, or coming to Hospital Property requesting (or obviously requiring) treatment for an Emergency Medical Condition receive an appropriate Medical Screening Examination...If an Emergency Medical Condition is determined to exist, such individuals are offered stabilizing treatment with the Hospital’s capabilities and/or are transferred if appropriate, all without regard to the patient’s insurance coverage or ability to pay...D. Special Circumstances: Withdrawal of Request for Examination: 1. If a patient withdraws his or her request for examination or treatment, an appropriately trained individual from the emergency department staff should discuss the medical issues related to a voluntary withdrawal. In the discussion, the emergency department staff member should: a. Offer the patient further medical examination and treatment as may be required to identify and stabilize and/or Emergency Medical Condition; b. Inform the patient of the benefits or the examination and/or treatment, and of the risks of withdrawal prior to receiving the examinations and/or treatment; and c. Use reasonable efforts to get the patient to sign a form indicating that the patient has refused the recommended examination and/or treatment. The form should contain a description of risks discussed and of the examination and/or treatment that was refused ...2. If a patient leaves the Hospital without notifying Hospital personnel, this should be documented. The documentation must reflect that the patient had been at the Hospital and the time the patient was discovered to have left the premises ....” Review of Patient #7 Emergency Department medical record physician documentation dated 03/21/2024 revealed: “...walk in with complaints of Abdominal pain 7 weeks preganant ...Differential diagnosis: Ectopic Pregnancy, Threatened abortion, Appendicitis, Colitis ...ED course: 0645 discussed again with patient and boyfriend the concerns regarding ectopic elevated white blood count, etc. She says she wants to leave but is convinced to stay ...0715 laying on the gurney to obtain the ultrasound she suddenly jumped up and says I am leaving, the ultrasound tech tries to reassure to stay but she refuses she grabs her clothes and runs to the exit. One of the nurses was able to take her IV out. Patient and boyfriend at this point are aware of the concerns regarding intra abdominal and intrauterine pathology and emergency. They understand the risks including miscarriage and death of the mother and baby. They have been encouraged to return at any time ...Disposition Summary: 03/21/2024 0725 Left Against Medical Advice ....” Further review of Patient #7 Emergency Department medical record revealed no evidence of a completed Leaving Against Medical Advice form signed by the patient nor any documentation that staff attempted to get Patient #7 to complete the required form indicating the patient was refusing further care and treatment. Employee #3 confirmed on 11/20/2024 that Patient #7 left against medical advice and the required AMA form was not present in the patient ’ s medical record. 2. Policy titled, “EMTALA- Medical Screening and Treatment of Emergency Medical Conditions”, revealed: “...To ensure that individuals coming to a Valley View Medical Center’s Dedicated Emergency Department seeking assessment or treatment for a medical condition, or coming to Hospital Property requesting (or obviously requiring) treatment for an Emergency Medical Condition receive an appropriate Medical Screening Examination...If an Emergency Medical Condition is determined to exist, such individuals are offered stabilizing treatment with the Hospital’s capabilities and/or are transferred if appropriate, all without regard to the patient’s insurance coverage or ability to pay...T. Stabilized with respect to an Emergency Medical Condition means that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from the facility or in the case of a woman in labor, that the woman delivered the child and the placenta. A patient deemed stabilized if the treating physician of the individual with an Emergency Medical Condition has been resolved ...U. To Stabilize means, with respect to an Emergency Medical Condition to either provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of individual form a facility or, in the case of a woman in labor, that the woman has delivered the child and the placenta ...V. Stable for Discharge: A patient is considered stable for discharge, when within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient or later as an inpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions ...Policy: Any individual who comes to the Hospital Property of Premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination performed by a physician or other Qualified Medical Personnel to determine whether or not an Emergency Medical Condition exists. If an Emergency Medical Condition is found to exist, the Hospital will (without regard for the patient ’ s insurance coverage or ability to pay) provide: (a) stabilizing treatment within the capabilities of the Hospital and its staff (including on-call physicians and diagnostic services)....” Review of Patient #18 Emergency Department medical record revealed a physician documentation note dated 05/18/2024 revealed: “...presents to the emergency department after leakage of fluid and some bleeding ...She is 16 weeks gestation with a Singleton pregnancy ...In the emergency department, fluid was essentially 0 ...There was a good heart rate in the 150s ...Prognosis is very grim however, I did talk to the patient about antibiotic prophylaxis and her and her husband did decide to be admitted to labor and delivery for IV antibiotics ...She will be seeing me in the office on a weekly basis for lab work and close follow-up ...They both understand that there is a very high possibility that the baby will not survive ...Assessment/Plan: 1 g Zithromax by mouth 2 g ampicillin IV q 6hours for 48 hours and then patient will be discharged home with Augmentin Regular diet Heart tones Q shift Patient understands there is a very high chance of intrauterine fetal demise Once discharged, patient wishes to remain under my care for prenatal care and she will see me on a weekly basis for blood work and ultrasound in the office, When discharged home,she will be on bedrest ... Active Medications: Ampicillin 2 GM IV q 6H Lactated ringers 1000ml one prn 999 ml/hr for fetal profusion-fetal distress ... HPI: presents to emergency department with no fetal movement, vaginal bleeding. The estimated gestational age is 16 weeks ... Has had multiple evaluations at HRMC including previous ultrasounds revealing low volume amniotic fluid. Possible loss of additional gestations reported by patient and family ...the patient has been recently seen by a physician with similar presenting complaints and apparently given a diagnosis of Low amniotic fluid, possible loss of early gestation fetus ...Procedures: 1526 Emergency medicine ultrasound by physician in ED, Gravid pregnancy: Indications Vaginal Bleeding Views: Uterus, IUP, Other: Placenta; Other Oligohydramnios, Diagnosis: Fetal demise ...Differential diagnosis: Active labor, ectopic pregnancy, preeclampsia, rupture of membranes, vaginal bleeding, vaginal delivery, IUFD (intrauterine fetal demise)...ED Course: repeat ultrasound was performed at 3:50 p.m. there was no additional amniotic fluid, however cardiac tones were visualized on this effort at about 150-160 discussed in person with the OBGYN physician at the bedside who also visualized the ultrasound and agreed to admit the patient for oligohydramnios and observation in L and D ...Final Impression:Potentially rule out: IUFD ...Disposition Summary: Hospitalization ordered ....” Further review of Patient #18 Emergency Department medical record revealed no documented evidence that alternative treatments for stabilization were discussed or provided for Patient #18 Employee #3 confirmed on 11/20/2024 that Patient #18 was made Observation status with obstetrics and was given antibiotics.”