Desert View Hospital

“This Statement of Deficiencies was generated as a result of a Medicare Life Safety Code (LSC) recertification survey conducted at your facility on 11/14/2023 and 11/15/2023, with additional documents received 11/16/2023. Your facility was surveyed using Chapter 19, “EXISTING” Health Care Occupancies of the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC); and NFPA 99, Health Care Facility Code 99 (HCFC), 2012 Edition. This was a two-story building (basement and grade-level) with a NFPA 220 construction type of Type II (111) and was equipped with an automatic fire sprinkler system. The facility was licensed for 25 medical surgical beds. The census was 18 at the time of survey. The facility was equipped with a Type 1 Essential Electrical System (EES). The facility had piped in Medical Gas; Oxygen, Vacuum, Medical Air, along with Nitrous Oxide and Nitrogen in the Operating Rooms. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigations, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following regulatory deficiencies were identified:”

“Alcohol Based Hand Rub Dispenser (ABHR) CFR(s): NFPA 101 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 This Standard is not met as evidenced by: 34576 Based on observation, the facility failed to ensure an alcohol based handrub dispenser (ABHR) was installed a safe distance from an ignition source as outlined in the Life Safety Code. Findings include: On 11/15/2023, observation within the fluoroscopy room revealed an alcohol based handrub dispenser (ABHR) was installed directly above the light switch. This observation was made in the presence of the Director of Plant Operations.”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 40450 National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code, 2010 Edition 10.5.5.2 Circuit Identification and Accessibility. 10.5.5.2.1 The location of the dedicated branch circuit disconnecting means shall be permanently identified at the control unit. 10.5.5.2.2 For fire alarm systems the circuit disconnecting means shall be identified as “FIRE ALARM CIRCUIT.” 10.5.5.2.3 For fire alarm systems the circuit disconnecting means shall have a red marking. 10.5.5.2.4 The circuit disconnecting means shall be accessible only to authorized personnel. ***** Based on observation, the facility failed to appropriately identify the fire alarm circuit in/on the electrical panelboard in accordance with NFPA 72, National Fire Alarm and Signaling Code. Findings include: On 11/14/2023 and 11/15/2023, observation of the facility’s electrical panelboards was conducted. The panelboard “ELSLB” revealed the fire alarm circuit was not appropriately identified with the wording, “FIRE ALARM CIRCUIT” and the circuit was not marked in red. In addition, circuit breaker #7 was labeled as “F/A Penthouse”. An interview with the Director of Plant Operations revealed the facility did not have a Penthouse and it was unknown if the circuit breaker actually sent power to a fire system component. On 11/15/2023, the panelboard “ELSL1” revealed the fire alarm circuits were marked in red but the labeling was not consistent with the required identification of “FIRE ALARM CIRCUIT”. The Director of Plant Operations acknowledged the findings as they were discovered. NOTE: The location of the dedicated branch circuit disconnecting means (on electrical panelboards) shall be permanently identified at the control unit using the words, “FIRE ALARM CIRCUIT” and shall be marked in red.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 40450 National Fire Protection Association (NFPA) 13, Standard For The Installation of Sprinkler Systems, 2010 Edition. Section 6.2.8 Guards. Sprinklers subject to mechanical injury shall be protected with listed guards. ***** Based on observation, the facility failed to ensure sprinkler guards were installed to protect fire sprinkler heads from mechanical injury within the kitchen walk-in refrigerator. Findings include: On 11/14/2023, the facility’s kitchen’s walk-in refrigerator and freezer were observed. The facility’s walk-in freezer was accessed by walking through the refrigerator and both had low-ceilings. The walk-in refrigerator was noted to contain one sprinkler head and the freezer did not have a sprinkler head. The refrigerator sprinkler head was observed to be located near the top shelves of the walk-ins and was not protected by a sprinkler guard, which subjected the head to possible mechanical injury. This observation was made in the presence of the Director of Plant Operations.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 40450 National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems, 2010 Edition 24.4 Instructions. The installing contractor shall provide the property owner or the property owner’s authorized representative with the following: (...) (2) NFPA 25, Standard for the inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (3) Physical damage (4) Loss of fluid in the glass bulb heat responsive element (5)* Loading 5.2.1.1.3* Any sprinkler that has been installed in the incorrect orientation shall be replaced. 5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation. 5.2.1.1.5 Glass bulb sprinklers shall be replaced if the bulbs have emptied. 5.2.2.2 Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe. 13.6.2 Testing (Back Flow) 13.6.2.1* All backflow preventers installed in fire protection system piping shall be tested annually by conducting a forward flow test of the system at the designed flow rate, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer. ***** Based on observation, interview and document review, the facility failed to test and maintain the automatic fire sprinkler system as required. Findings include: On 11/14/2023 and 11/15/2023, document review and observations during a tour of the facility revealed the following: 1) The facility did not have a copy of the NFPA 25. (Copy required by NFPA 13) 2) During a tour of the facility fire sprinklers were observed to be loaded or were covered in an unidentifiable substance in the following areas: a. Kitchen: six of nine sprinkler heads in the main food preparation area b. CAT Scan Control Room: four sprinkler heads 3) The interstitial space above the smoke barrier cross corridor doors located adjacent to the maintenance room was observed with the following: a. Low voltage electrical wiring was hung over the sprinkler pipes and; b. Insulated duct work was observed touching or leaning on the sprinkler piping. 4) The vendor report dated 02/06/2023 indicated the backflow devices were last tested on 09/08/2022. There was no supportive documentation to show an annual backflow test had been completed as required. The facility’s vendor was present during the discovery and the Director of Plant Operations was informed of the findings as they were discovered.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 40450 National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition. Article 314 - Outlet, Device, Pull, and Junction Boxes; Conduit bodies; Fittings; and Handhole Enclosures 314.28 Pull and Junction Boxes and Conduit Bodies. (...)(C) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110. Article 406 - Receptacles, Cord Connectors, and Attachment Plugs (Caps) Article 406.9 Receptacles in Damp of Wet Locations (...)(B) Wet Locations. (1) 15- and 20-Ampere Receptacles in a Wet Location. 15- and 20-ampere, 125- and 250-volt receptacles install in a wet location shall have an enclosure that is weatherproof whether or not the attachment plug cap is inserted. For other than one- or two-family dwellings, an outlet box hood installed for this purpose shall be listed, and where installed on an enclosure supported from grade as described in 314.23(B) or as described in 314.23(F) shall be identified as “extra-duty.” All 15- and 20-ampere, 125- and 250-volt nonlocking-type receptacles shall be listed weather-resistant type. ****** Based on observation, interview and document review, the facility failed to ensure the facility had installed and/or maintained the electrical system within the building per NFPA 70, National Electrical Code. Findings include: On 11/14/2023 and 11/15/2023, a tour of the facility revealed the following electrical code deficiencies: 1. Observation of the interstitial space located at the smoke barrier cross corridor doors adjacent to the Maintenance shop room revealed an uncovered red junction box. (Junction box covers shall be provided.) 2. The Janitors closet located in the kitchen was observed. There was a Ground Fault Circuit Interrupter (GFCI) protected duplex receptacle installed approximately 18 inches from the floor, adjacent to the mop sink. The outlet did not have an enclosure that was weatherproof (designed for wet locations). 3. The GFCI protected duplex receptacle located in the Janitors closet had been tripped (activated). The Director of Plant Operations was not aware the receptacle had been tripped and was unaware as to the reason for its activation at the time of discovery. The Director of Plant Operations acknowledged the above noted findings as they were discovered.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 40450 National Fire Protection Association (NFPA) 99, Health Care Facilities Code. 2012 Edition. 6.5.2.2.2 Life Safety Branch. 6..5.2.2.2.1 The life safety and critical branches shall supply power for lighting, receptacles, and equipment as follows: (1) Illumination of means of egress in accordance with NFPA 101, Life Safety Code (2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code (3) Alarm and alerting systems, including the following: (a) Fire alarms (b) Alarms required for systems used for the piping of non-flammable medical gases as specified in Chapter 5 (4)* Communications systems, where used for issuing instructions during emergency conditions (5) Sufficient lighting in dining and recreation areas to provide illumination to exit ways of a minimum of 5 ft-candles (6) Task illumination and select receptacles at the generator set location (7) Elevator cab lighting, control, communications, and signal systems 6.5.2.2.2.2 No functions other than those listed in 6.5.2.2.2.1 (1) through (7), shall be connected to the life safety. National Fire Protection Association (NFPA) 70, National Electric Code. 2011 Edition. Article 408.4 - Field Identification Required A) Circuit Directory of Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include an approved degree of detail that allows each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard and at each switch or circuit breaker in a switchboard or switchgear. No circuit shall be described in a manner that depends on transient conditions of occupancy. ***** Based on observation and interview, the facility failed to ensure the Life Safety Branch of the Essential Electrical System did not include prohibited functions. Findings include: Based on observation and interview, the facility failed to ensure the Life Safety Branch(es) of the Essential Electrical System supplied power to the required lighting, receptacles, equipment and did not include prohibited functions. Findings include: On 11/14/2023 and 11/15/2023, while touring the facility’s electrical room(s), the life safety branches (LSB) as identified by the maintenance staff were inspected. The following observations were made for panels ELSLB, ELSL1 SEC 1 and SEC 2, EQLB, CBL1 SEC 1 and SEC2. The electrical panel schedules lacked circuit breaker details as noted below. 1) Circuit breaker labels had minimal description for what was being powered and did not indicate specific locations for the following: a. corridor lighting, b. receptacles for emergency power and, c. fire system components to include the Fire Alarm Annunciator or the Fire Alarm Control Panel. 2) Other schedules associated with the life safety branches had circuit breakers labeled as: a. “UPS BATT BACKUP 151” but it was unclear as to what device would be supplied power if on generator power, b. “FIRE DAMPER” the location for the fire damper was not specified, c. “PATIENT AREA S/D” it was unknown which patient area the smoke damper was located and, d. “EMERGENCY S/D” it was unknown where in the emergency room or area the smoke damper was located. 3) Additional observations, interviews and a review of the on-site electrical system(s) as-built line drawings could not determine which circuit breaker supplied power to each individual fire/smoke damper nor matched what was denoted on the line drawings for the facilities electrical panels. The Director of Environmental Services acknowledged the findings as they were discovered.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 40450 Based on observation and interview, the facility failed to properly identify and segregate medical gas (oxygen) cylinders as required. Findings include: On 11/14/23 and 11/15/2023, while touring the facility all patient care areas or rooms had full E-size oxygen cylinders. The areas or rooms where the cylinders were observed included but were not limited to the PACU bays, the ER rooms, the nuclear medicine rooms and in addition to the rooms, tanks were also attached to the patient gurneys. The facility failed to have the appropriate markings or signage to identify the empty, partially full or partially empty and full E-size oxygen cylinders in order to prevent commingling or confusion. On 11/16/2023, document review of the facility’s policy entitled “Oxygen Review” revealed a section subtitled “Storage”. This section read as follows: 1. “Storing oxygen cylinders is about managing empty cylinders. Those cylinders defined as PSI of 500 or less. Any oxygen tank with PSI of 500 or less will be segregated from all other cylinders that are intended for patient care use. Empty cylinders shall be marked as such by either individual tagging, as indicated by the integral gauge, or group signage. (Example) Empty E tanks will be placed in a tank rack with a sign “EMPTY” on it.” 2. “All full oxygen tanks will be stored in a rack with a sign “FULL” attached to it.” 3. “All oxygen tanks with less than 2000 psi but more than 500 psi will be considered partially full and will be stored in a rack with a sign “PARTIALLY FULL” attached to it.” The facility was not following their own policy for the storage, proper signage as detailed in the policy document. The Director of Plant Operations and the Director of Nursing were present each time E-size cylinders were found in patient care areas.”

“Establishment of the Emergency Program (EP) CFR(s): §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: 28154 Based on a review of the facility’s Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), and staff interview, the Critical Access Hospital (CAH) failed to establish a Comprehensive Emergency Preparedness Program that complies with all applicable Federal Emergency Preparedness requirements that is based off the facility’s all hazard risk assessment and patient population it serves. This deficient practice has the potential to put the current receiving care in the facility, any outpatients currently receiving care in the facility, and facility staff at risk in the event of an emergent event. Findings include: Review of page 5 of 38 of the facility’s EPP indicated: “Introduction ...a 25-bed critical access facility in Pahrump, NV providing emergency and surgical services to a rural area ...has organized, developed, and implemented an Emergency Management Program. The plan will: 1. Prevent or lessen the impact that a disaster may have on the hospital and the community (Mitigation). 2. Identify resources essential to disaster response and recovery facilitating their access and utilization (Preparedness). 3. Prepare staff to respond effectively to disasters or emergency situations that affect the environment of care and test response mechanisms (Response). 4. Plan processes for reestablishing operations after the incident (Recovery).” Page 6 of 38 stated: “The Emergency Operations Plan describes a comprehensive “all hazards” response structure for coordinating the six critical areas: communications, resources and assets, safety and security, staffing, utilities and clinical activities. . ..” Review of the agency’s binder labeled “Emergency Preparedness” revealed that the binder contained an EPP that was reviewed on 05/22/2023 however, the plan did not contain a Comprehensive Emergency Preparedness Plan including the Emergency Preparedness Conditions of Participation, based on the agency’s all hazard risk assessment and patient population. (See findings in Tags E0004, E0006, E0007, E0013, E0015, E0018, E0020, E0022, E0023, E0024, E0030, E0032, E0033, and E0039.)”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 28154 Based on observation, interview, policy review, and review of the manufacturer’s instruction for use of disinfection wipes, the facility failed to ensure staff were following the instructions to ensure compliance with the infection control processes. This failure had the potential to affect the 18 patients and/or the outpatients receiving treatment in the operating rooms (ORs). Findings include: During an observation on 11/08/2023 at 11:02 AM, the Environmental Services (EVS) employee entered Operating Room 2 (OR2) and started to wipe down equipment. When asked about the product being used, EVS stated, “the purple top ones.” Review of the container with the purple top showed it was a “PDI Sani Cloth” wipe. EVS was observed to clean the electronic equipment, intravenous (IV) poles, directional light, table, cords etc. Responding to a question regarding contact time (explained wet time, dwell time three different times) at 11:06 AM, EVS stated “It dries right away though it says two minutes. It’s alcohol so it dries right away.” At 11:10 AM on 11/08/2023, Registered Nurse (RN)5 entered OR2 and started wiping down the stainless-steel table with PDI Sani Cloths. When asked about the contact time for the disinfecting wipe, RN5 stated, “May I refer to something? I error on the side of caution and it’s three minutes from the time I stop wiping to before I put anything on the table.” When asked if that was wet time, RN5 stated, “I just wait three minutes.” RN5 was observed watching the clock and started setting up the table at 11:15 AM. In the anteroom (room with supplies) between the two ORs was another tub of wipes. On 11/08/2023 at 11:17 AM, EVS was going to OR1 to clean and was asked about the second tub of wipes “Diversey Easy Wipe.” EVS explained that was a Virex wipe that EVS pours in the solution and that those wipes were used for terminal cleaning at the end of the day. The container was not marked with any indication of what solution was on the wipes. On 11/08/2023 at 11:54 AM, the Sterile Processing Technician (SPT) was observed wiping down the scope cleaning sinks with PDI Sani Cloths, even though water droplets remained on sides and bottom of sinks and ledges around the sinks. Then at 11:55 AM, SPT removed a plastic liner from a bin used to transport dirty endoscopes, disposing of the liner; performed a glove change, then used a PDI Sani Cloth on the interior and exterior of the bin. SPT walked a few feet further into the processing room and put the gray tray onto a cart. The tray was observed to be drying/streaking. SPT confirmed at 11:57 AM that within ten seconds of wiping the tray was showing signs of drying already. Review of the facility printed “PDI Super Sani Cloth” instructions for use, provided by the facility Infection Preventionist (IP) showed: “ . . . 3b Unfold a clean wipe and thoroughly wet surface. 4. Allow the treated surface to remain wet for two (2) minutes. Let air dry. . ..” The IP confirmed the surface is to stay wet for two minutes. Review of the facility policy titled “Cleaning and Disinfection of Reusable Patient Care Equipment,” last revised 09/2023, showed: “III. Policy: A. Equipment will be clean with a hospital approved disinfectant, per manufacturer’s instructions, after each patient use and on a regular schedule. . ..” Review of the facility policy titled “Environmental Cleaning,” last revised 01/01/18 showed: “. . .IV. Procedure: . . . 2. Cleaning of OR/procedure room between procedures must be done with a facility-approved, EPA-registered disinfectant. . ..””

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 28154 Based on interview and review of the facility’s Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP documented the development of an all hazards-based facility and/or community risk assessment. This failure had the potential to affect the current patients receiving care in the facility and any outpatients that are receiving care in the facility. Findings include: During a review of the facility EPP on 11/08/2023 at 1:56 PM, with the Director of Plant Operations no documentation of an all hazards-based facility and/or community risk assessment was located on which the EPP policies were developed. Page 8 of 38 showed: “Planning Activities -Hazard Vulnerability Analysis ...Hospital identifies the potential emergencies that could affect demand for the hospital’s services or its ability to provide those services, the likelihood of those events occurring, and the consequences of those events annually and when new services are added. This assessment is a Hazard Vulnerability Analysis (HVA), which is designed to assist in gaining a realist understanding of the vulnerabilities and to help focus the hospital’s resources and planning efforts. All locations (main campus, offsite services, etc.) are required to have a HVA ...The community and regional HVA assessments, risk assessments and alerts also aid in the HVA assessment. A list of priority concerns is developed from the HVA and is evaluated annually. A copy of the most current HVA is attached.” There was no HVA attached. During an interview on 11/08/2023 at 1:59 PM regarding the risk or HVA assessment, the Director of Plant Operations stated, “I don’t recall it in here.” No HVA was provided during the following business day afforded to the facility.”

“Plan Based on All Hazards Risk Assessment CFR(s): §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: 28154 Based on interview and review of the facility’s Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies were based on an all hazards-based facility and/or community risk assessment. This failure had the potential to affect the current patients receiving care in the facility and any outpatients that receiving care in the facility. Findings include: During a review of the facility EPP on 11/08/2023 at 1:56 PM, with the Director of Plant Operations (DPO), no documentation of an all hazards-based facility and/or community risk assessment was located on which the EPP policies were developed. During an interview on 11/08/2023 at 2:03 PM, the Director of Plant Operations confirmed there was no hazard risk assessment in the EPP.”

“EP Program Patient Population CFR(s): §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: 28154 Based on interview and review of the facility’s Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies identified the patient population that would be at risk during an emergent event. This failure had the potential to affect the current patients receiving care in the facility and any outpatients that receiving care in the facility. Findings include: Review of the facility’s EPP on 11/08/2023 at 1:56 PM, with the Director of Plant Operations (DPO), revealed that the EPP did not address the patient population that would be at risk in the event of an emergency event. During an interview on 11/08/2023 at 2:05 PM while reviewing the EPP, the Director of Plant Operations was asked if the at-risk patient population was identified with strategies to address at risk patient needs responded “No, I don’t believe so.””

“Development of EP Policies and Procedures CFR(s): §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: 28154 Based on interview and review of the facility’s Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies and procedures were developed based on the risk assessment. This failure had the potential to negatively affect the current patients and/or staff in the facility in the event of an emergency. Findings include: During a review of the facility EPP on 11/08/2023 at 1:56 PM, with the Director of Plant Operations (DPO), no documentation was found to show the EPP was developed from the risk assessment. During an interview on 11/08/2023 at 2:22 PM, the Director of Plant Operations confirmed there was no risk assessment.”

“Subsistence Needs for Staff and Patients CFR(s): §403.748(b)(1), §418.113(b)(6)(iii), §441.184(b)(1), §460.84(b)(1), §482.15(b)(1), §483.73(b)(1), §483.475(b)(1), §485.542(b)(1), §485.625(b)(1) [(b) Policies and procedures. [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 every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal. This Standard is not met as evidenced by: 28154 Based on interview and review of the facility’s Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies addressed the subsistence needs of food and pharmaceuticals for the patients and staff in an emergency event. This failure had the potential to affect the current patients receiving care at the facility and any outpatients that are receiving care in the facility. Findings include: During a review of the facility EPP on 11/08/2023 at 1:56 PM, the Director of Plant Operations (DPO), revealed there was no policy or procedure regarding food and pharmaceutical subsistence needs of staff and patients listed during an emergent event. During an interview on 11/08/2023 at 2:28 PM, the Director of Plant Operations confirmed the food and pharmaceutical needs were not addressed.”

“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: 28154 Based on interview and review of the facility’s Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies addressed a system of tracking for staff and sheltered patients during an emergent event. This failure had the potential to affect the current patients receiving care in the facility, any outpatients that receiving care in the facility, and facility staff present. Findings include: During a review of the facility EPP on 11/08/2023 at 1:56 PM with the Director of Plant Operations, no policy, procedure, or tracking system was located in the emergency plan. Review of the facility “Emergency Operations Plan” on page 35 was: “-Patient Tracking: Internal and External In departments that may receive disaster patients, such as the Emergency Department and patient care units, via transfers from another facility or campus locations, patient trackers will be assigned to track the patients entering and leaving the areas. . .. The form used for patient tracking will be the . . . -Disaster Victim Patient Tracking Form.” [sic] During an interview on 11/08/2023 at 2:31 PM, the Director of Plant Operations stated, “We do not have this tracking system currently.””

“Policies for Evac. and Primary/Alt. Comm. CFR(s): §403.748(b)(3), §416.54(b)(2), §418.113(b)(6)(ii), §441.184(b)(3), §460.84(b)(3), §482.15(b)(3), §483.73(b)(3), §483.475(b)(3), §485.68(b)(1), §485.542(b)(3), §485.625(b)(3), §485.727(b)(1), §485.920(b)(2), §491.12(b)(1), §494.62(b)(2) [(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:] [(3) or (1), (2), (6)] Safe evacuation from the [facility], 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 RNHCIs at §403.748(b)(3) and ASCs at §416.54(b)(2) and REHs at §485.542(b)(3):] Safe evacuation from the [RNHCI or ASC or REHs] which includes the following: (i) Consideration of care needs of evacuees. (ii) Staff responsibilities. (iii) Transportation. (iv) Identification of evacuation location(s). (v) Primary and alternate means of communication with external sources of assistance. * [For CORFs at §485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at §485.727(b)(1), and ESRD Facilities at §494.62(b)(2):] Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services; and ESRD Facilities], which includes staff responsibilities, and needs of the patients. * [For RHCs/FQHCs at §491.12(b)(1):] Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; staff responsibilities and needs of the patients. This Standard is not met as evidenced by: 28154 Based on interview and review of the facility’s Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP addressed a plan for the safe evacuation of the facility. This failure had the potential to affect the current patients receiving care in the facility, any outpatients receiving care in the facility, and staff working at the time an evacuation may be required. Findings include: During a review of the facility EPP on 11/08/2023 at 1:56 PM with the Director of Plant Operations, no policy or procedures regarding safe evacuation from the facility was located in the emergency plan. Review of page 34 of 38 of the facility “Emergency Operations Plan” showed: “Managing Patient Clinical and Support Activities . . . Evacuation Activities -An evacuation of the hospital for a situation that renders the facility no longer capable of providing the necessary support for patient care, treatment, and services, should be directed by the Incident Commander. The evacuation should be handled in cooperation with local police or fire and/or local . . .. -The local police or fires and/or EOC [sic] should be notified as soon as the potential for evacuation is considered and should be kept updated on an ongoing basis in order to begin the process for identification of the availability of vehicles to relocate the patients. Procedures utilized during an evacuation process are identified in the hospital Evacuation Plan. Patient location will be using a Master Evacuation Tracing Form . . .” During an interview on 11/08/2023 at 2:34 PM, the Director of Plant Operations stated, “[Evacuation procedures are] Not included right now.””

“Policies/Procedures for Sheltering in Place CFR(s): §403.748(b)(4), §416.54(b)(3), §418.113(b)(6)(i), §441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.542(b)(4), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3). (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:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice. This Standard is not met as evidenced by: 28154 Based on interview and review of the facility’s Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies addressed procedures for sheltering in place for patients, staff, visitors, and/or outpatients present during an emergency event. This failure had the potential to affect the current patients receiving care in the facility and any outpatients that are receiving care in the facility. Findings include: During a review of the facility EPP on 11/08/2023 at 1:56 PM with the Director of Plant Operations, there was no policy or procedures regarding the sheltering in place for anyone in the facility during an emergent event. During an interview on 11/08/2023 at 2:35 PM regarding procedures for sheltering in place, the Director of Plant Operations, “Nothing regarding sheltering in place is in there.””

“Policies/Procedures for Medical Documentation CFR(s): §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(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:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[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. This Standard is not met as evidenced by: 28154 Based on interview and a review of the facility Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to identify a system of medical documentation that preserves patient information, protects the confidentiality of patient information, secures, and maintains the availability of patient records. This failure had the potential to affect the current patients receiving care in the facility and/or any outpatients receiving treatment in the facility. Findings include: Review of the facility EPP on 11/08/23 at 1:56 PM with the Director of Plant Operations did not reveal any policy or procedure that identifies the system of medical documentation that preserves resident information; provides for the confidentiality of resident information; and secures, maintains, the availability of resident records in the case of an emergent event. In an interview on 11/08/23 at 1:56 PM, when asked if the EPP included a policy or procedure that addressed a medical record system that secured and maintained the availability of patient records, the Director of Plant Operations responded “No.””

“Policies/Procedures-Volunteers and Staffing CFR(s): §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(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:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: 28154 Based on interview and review of the facility’s Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies addressed the use of federal or state healthcare volunteers to meet staffing requirements during an emergency event. This failure had the potential to affect the current patients receiving care in the facility and any outpatients that are receiving care in the facility. Findings include: Review of the facility’s EPP revealed no policy inclusion regarding the use of State and/or Federal healthcare professional volunteers in an emergency, or other emergency staffing strategies. On pages 35 and 36 of 38 of the facility “Emergency Operations Plan” showed: “Disaster Privileges -Volunteer Licensed Independent Practitioners (LIP) The hospital grants disaster privileges to volunteer licensed independent practitioners (LIP) when the Emergency Operations Plan has been activated . . . The policy and procedure identifying the hospitals’ management of this process is located in the Valley Health System Policy: Medical Staff Disaster Privileges. We don’t have this policy - you will need to attain this policy from . . . and assure that it is appropriate for DVH based on medical staff guidelines. -Other Licensed Volunteers The hospital assigns disaster responsibilities . . . The policy on Other Licensed Volunteers is the Valley Health System Licensure/Certification/Registration Policy. During an interview on 11/08/2023 at 2:40 PM regarding federal and state healthcare volunteers, the Director of Plant Operations stated, “No current policy.””

“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: 28154 Based on interview and review of the facility’s Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the Critical Access Hospital (CAH) failed to maintain a current list of names and contact information in the “Emergency Preparedness Communication Plan” that included all facility staff members and patient physicians. This failure had the potential to affect the patients receiving care in the facility and could delay the facility’s ability to respond to an emergency. Findings include: Review of the facility’s EPP Communication Plan on 11/08/2023 at 1:56 PM with the Director of Plant Operations showed the plan did not include identification of all the facility’s staff and their contact information (only administrative staff were identified), nor did it include a list of patient physicians and their contact information. In an interview on 11/08/2023 at 2:48 PM, the Director of Plant Operations confirmed only facility administrative staff were identified. When asked about the inclusion of patient physicians contact information, the Director of Plant Operations stated, “No.””

“Primary/Alternate Means for Communication CFR(s): §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: 28154 Based on interview and review of the facility’s Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP communication plan addressed the means of communicating with the federal and state emergency management agencies. This failure had the potential to affect the current patients receiving care in the facility, any outpatients that receiving care in the facility, and hindered the facility’s ability to prepare for potential emergency situations. Findings include: Review of the facility EPP Communications Plan on 11/08/2023 at 1:56 PM with the Director of Plant Operations did not reveal primary and alternate methods of communication with the federal and state emergency management agencies. In an interview on 11/08/2023 at 2:51 PM the Director of Plant Operations confirmed the federal and state emergency management agencies were not included, stating, “I don’t believe so.””

“Methods for Sharing Information CFR(s): §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(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: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: 28154 Based on interview and review of the facility’s Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP Communication Plan included written a written policy or procedure that addressed the sharing of information and medical documentation for patients under the facility care. This failure had the potential to affect the current patients receiving care in the facility and any outpatients that receive care in the facility. Findings include: A review of the facility’s EPP communication plan on 11/08/2023 at 1:56 PM with the Director of Plant Operations did not show a written policy or procedure for the sharing of patient information and medical documentation with another provider in an emergent event. In an interview on 11/08/2023 at 2:54 PM, the Director of Plant Operations confirmed there was no identified method for sharing information and/or medical documentation in writing in the EPP, stating, “No, [it’s] not addressed.””

“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: 28154 Based on interview and review of the facility’s documentation, the facility failed to ensure the Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP) documented an annual community based full scale exercises to test the EPP; or the documentation of facility efforts to identify a full-scale community-based exercise; or an individual facility based functional exercise twice a year. This failure had the potential to affect current patients, any outpatients receiving treatments, staff, volunteers, or visitors in the facility in an emergent event. Findings include: Review of the facility EPP on 11/08/2023 at 1:56 PM with the Director of Plant Operations did not reveal any documentation of facility participation in community or facility-based exercises to test their emergency plan. During an interview on 11/08/2023 at 2:57 PM regarding the exercises, the Director of Plant Operations had been there about a year, and they have not had an emergency exercise.”