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The following deficiencies were identified at the time of the unannounced, onsite State Compliance Survey, Event #1UV511, conducted on 07/12/2021, through 07/15/2021, pursuant to the rules found in the Arizona Administrative Code (A.A.C.) Title 9, Chapter 10, Article 2 - Hospitals.

Based on review of the facility's policies and procedures, documents, Electronic Medical Record (EMR) and staff interviews, it was determined the governing body failed to ensure that all patient care is provided by or in accordance with the orders of a practitioner who has been granted privileges in accordance with the criteria established by the governing body. Outpatients are being discharged from the Emergency Department (ED) without a discharge order being documented by a medical practitioner who provided medical services to the patient before the patient is discharged. This deficient practice poses the risk of a potential harm to patients being discharged before their care is complete, or assuring the patient is stable for transfer or discharge.

Findings include:

The facility's policy titled "Discharge Planning" revealed "...Procedure: A. Special Considerations...2. No patient will be discharged or transferred without a physician's order...."

The facility's document titled "Medical Staff Rules and Regulations" revealed "...1.12 Transfers a) When patients are discharged and sent to another licensed healthcare...without the intent of return to the sending hospital, practitioners shall follow federal/state standards. The attending practitioner is responsible for: i. ordering the patient transfer ii. determining the patient's condition for transfer - stable versus unstable...viii. documenting thoroughly...1.14 Discharges...b) Patient shall be discharged only by order of the attending practitioner or designee...."

Review of records from the facility's Emergency Department (ED) for patient's #5, #11, #12, #13, #14, #15, #16, and #17, revealed 8 of 8 patient records of patient's being transferred or discharged from the facility's ED contained no physician order for transfer or discharge.

Interview with Employee #5 on 07/13/2021 at 1410 confirmed that there were no discharge or transfer orders in the EMR for patient #5.

Interview with Employee #8 on 07/14/2021 at 1005 confirmed that there were no discharge or transfer orders in the EMR for patients #11, #12, #13, #14, #15, #16, and #17. Employee #8 further confirmed the ED physicians do not write orders for discharge or transfer.

Based on review of the facility Emergency Plan, record review and staff interview, it was determined, the facility failed to develop a facility-based and a community-based risk assessment prior to developing the facility's emergency plan. Failure to develop emergency plans based on community-based risk assessment poses a potential risk and may cause harm to the patients and staff during an emergency, if specific needs of both the patient and staff are not identified as part of the EP plan.

Findings include:


Observations made during document review made on July 19, 2021 revealed the facility failed to optain a community-based risk assessment and use it to develop a facility-based risk assessment prior to developing the facility's emergency plan for the satilite facilities located in different geographic areas. The facilities located in Holbrook, Snowflake/Taylor

Employees #9 acknowledged during the exit conferance that the facility did not optain a community based risk assessment and use it to create the facilities Emergency Plan for the remote facilities.

Based on record review and interview it was determined the facility did not have documentation in the emergency preparedness communication plan that complies with Federal, State and local laws that included a method for sharing information. Failure to have a means to share private information to assist in patient care could result in miss information being provided to other providers providing care for the facility's patients.



Findings include:

Finding during the document review process July 15, 2021 the facilities Emergency Plan did not include policies and procedures, in the communication plan for the following:
1. Sharing information and medical documentation for patients under the facility's care, as necessary, with other health providers to maintain the continuity of care.
2. A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510.
3. 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.


Employee #9 acknowledged during the exit conference that the facility did not identify a method for sharing information and medical documentation for patients under the facilities care as required and develop policy and/or procedures that address the means the facility will use to release patient information to include the general condition and location of patients.

Based on review of the facilities emergency plan and staff interview, it was determined the facility failed to have the new and existing staff review the emergency preparedness plan. Failure to have staff review the emergency preparedness plan consistent with their expected roles may cause harm to the residents and/or staff during an emergency.

Findings include:

Observations, interview and record review made on July 12-15, 2021, revealed the facility failed to provide documentation that new and existing staff reviewed the emergency preparedness policies and procedures. The personnel in the provider based facilities were unable to recall any training related to the CMS requires Emergency Preparedness training. The Facility was not able to prove those individuals had initial or ongoing training related to EP.

Employee #9 acknowledged during the exit interview the facility failed to provide documentation that new and existing staff in the provider based OTC's had any training related the emergency preparedness policies and procedures or the EP program.

Based on review of the facilities Emergency Preparedness testing requirements, record review and staff interview, it was determined the facility failed to participate in drills as required. Failure to participate in drills may lead to untrained staff in an emergency situation and may result in harm to the residents during an emergency.


Findings include:

During document review on July 15, 2021 it was revealed the facility was missing documents proving participation in a full-scale exercise (FSE) that was community-based that included all of the provider based facilities(satelitte). The facility was also missing documents proving a facility-based exercise or table top drill for 2018, 2019 or 2020 that proved participation from the satellite facility's.

Employee #9 acknowledged during the exit interview that the facility was not able to locate proof of participation in a full-scale exercise that was community-based or a facility based exercise in the last two cycles for all their satellite facilities.

Based on review of the facilities Emergency Plan and staff interview, it was determined that the facility is a part of a Integrated Healthcare System and could not demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated Emergency Preparedness program. Additionally the facility was unable to provide documentation of a community-based or a facility-based risk assessment, utilizing an all hazard approach. Failure to have an integrated EP program may lead to confusion and disorganization during an emergency. Confusion and disorganization may lead to patient harm.

Findings include:

Observations during document review on July 15, 2021, showed the hospital EP program was unable to provide documentation that each separately certified facility within the system actively participated in the development of the unified and integrated Emergency Preparedness program. Additionally the facility was unable to provide documentation of a community or facility based risk assessment for all the facilityies, utilizing an all hazard approach.

Employee #9 acknowledged during the exit conference on July 19, 2021 that the facility failed to incorporate the satellite facilities into their integrated EP program.