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Based on review of the hospital's Governing Body By-Laws, contract list, and interview, it was determined the hospital failed to require that the Governing Body review the contract list, and ensure that each contract is reviewed evaluating compliance for quality and safe patient care. This deficient practice poses a risk to the health and safety of the patient(s), when there is no oversight or evaluation of services furnished under contract providing patient care.

Findings include:

Document titled "Governing Board By-Laws of Haven Behavioral Hospital of Phoenix" (#7707275; 02/2020), revealed: "...Purpose...promote performance improvement and quality patient care...oversee management and planning...Functions and Duties...of the Governing Board...consistent with...all applicable State and Federal laws and regulations...Governing Board Operation...Performance Improvement...shall require...each of the hospital departments or services to implement and report on mechanisms for monitoring and evaluating the quality of patient care, for identifying opportunities to improve patient care...a plan for an on-going quality management program that includes at a minimum all components required by applicable Federal and State law...for documented reports to be submitted to the Governing Board identifying concerns about the delivery of hospital services...Governing Board shall...act on, the results reported from performance improvement activities...the provision of quality patient care by...all others who provide patient care services...."

Document titled "Senior Horizons, Vendor Contracts" (no date), revealed the following:

i. A list of twenty (20) vendors/contracted services;
ii. Two (2) out of twenty (20) vendors/contracted services had no expiration date or auto annual renewal;
iii. No documented evidence that each vendor/contracted service had been evaluated under the quality assessment and performance improvement evaluation.

Document titled "Governing Body Meeting Minutes" (04/21/2020), revealed the following:

i. Annual approval of the Contract List;
ii. No documented evidence of a quality assessment and performance improvement evaluation for each vendor/contract service listed.

Personnel #4 confirmed during an interview conducted 09/17/2020 (1103), that the Governing Body had not approved the "Vendor Contract" list, to include documented evidence of an annual quality assessment and performance improvement evaluation for each vendor/contract service listed.

Based on review of hospital policies/procedures, staffing assignment sheets, acuity staffing tools, and interviews, it was determined that the hospital failed to require that nursing staff assignments were made according to patient acuity. This deficient practice poses a risk to the health and safety of the patients, when the hospital does not staff according to acuity, to identify and meet the individual needs of the patients.

Findings include:

Policy titled "Nursing Acuity and Staffing Plan-Phoenix" (#7671515; 02/2020), revealed: "...Nursing Department...maintains a system for determing patient requirements for nursing care on the basis of demonstrated patient needs...nursing intervention...priority care...this is the method used for establishing nursing staff needs and requirements for each patient unit based on the patient's acuity level...patient care assignments are based on patient acuity...staffing assignments will be documented on the Staffing Assignment Sheet...Acuity Level...to provide a framework for nursing staff to evaluate the nurse-to-patient ratio and nursing level of care needed...provide for adequate coverage and ensure a safe and therapeutic environment...is the responsibility of nursing leadership to ensure that the patient acuity level is consistently utilized in order to provide the staffing required for patient care...."

Document titled "Governing Board ByLaws of Haven Behavioral Hospital of Phoenix" (#7707275; 02/2020), revealed: "...principal purposes of the Governing Board...to promote...quality patient care...oversee management and planning of hospital...Patient Care...Governing Board shall support and participate in an institutional process to periodically review, evaluate, and revise hospital policies and procedures...."

Documents titled "Haven Acuity Staffing Tool", "Staff Assignment Sheet", and "Shift Assignments", revealed the following:

Mesquite Unit: Census 27 (09/16/2020 and 09/17/2020)

i. 09/16/2020: Haven Acuity Staffing Tool (morning/afternoon). Based on current acuity: # of RN/LVN resources = 3; # of BHT Resources = 3; No variance noted;
ii 09/16/2020: Day Staff Assignment Sheet - # of RN's = 3; # of BHT's = 3; Acuity score documented for each patient, but total acuity score for each RN and/or BHT not totaled;
iii. 09/16/2020: Night Staff Assignment Sheet - # of RN's = 3; # of BHT's = 3; Acuity score documented for each patient, but total acuity score for each RN and/or BHT not totaled;
iv. 09/17/2020: Day Staff Assignment Sheet - # of RN's = 3; # of BHT's = 3; Acuity score documented for each patient, but total acuity score for each RN and/or BHT not totaled;
v. Assignments made in blocks according to room location.

Juniper Unit: Census 16 (09/16/2020 and 09/17/2020)

i. 09/16/2020: Haven Acuity Staffing Tool (morning/afternoon). Based on current acuity: # of RN/LVN resources = 2; # of BHT Resources = 3; No variance noted;
ii 09/16/2020: Day Staff Assignment Sheet - # of RN's = 2; # of BHT's = 2; Acuity score documented for each patient, but total acuity score for each RN and/or BHT not totaled;
iii. 09/16/2020: Night Staff Assignment Sheet - # of RN's = 2; # of BHT's = 2; Acuity score documented for each patient, but total acuity score for each RN and/or BHT not totaled;
iv. 09/17/2020: Day Staff Assignment Sheet - # of RN's = 2; # of BHT's = 2; Acuity score documented for each patient, but total acuity score for each RN and/or BHT not totaled;
v. Assignments made in blocks according to room location.

Palo Verde Unit: Census 11 (09/16/2020-AM), Census 10 (09/16/2020-PM), and Census 12 (09/17/2020-AM)

i. 09/16/2020: Haven Acuity Staffing Tool (morning/afternoon). Based on current acuity: # of RN/LVN resources = 1; # of BHT Resources = 1; No variance noted;
ii 09/16/2020: Day Staff Assignment Sheet - # of RN's = 1; # of BHT's = 2; Acuity score documented for each patient, but total acuity score for each RN and/or BHT not totaled;
iii. 09/16/2020: Night Staff Assignment Sheet - # of RN's = 1; # of BHT's = 2; Acuity score documented for each patient, but total acuity score for each RN and/or BHT not totaled;
iv. 09/17/2020: Day Staff Assignment Sheet - # of RN's = 1; # of BHT's = 2 (one RN working as a BHT); Acuity score documented for each patient, but total acuity score for each RN and/or BHT not totaled;
v. Assignments made in blocks according to room location.

Observations on tour conducted 09/16/2020, with Personnel #3, and Personnel #7, revealed the following:

i. (1240) - Palo Verde Unit: one (1) float RN in the medication room (but not passing medications);
ii. (1320) - Juniper Unit: one (1) RN, and one (1) LPN left the unit for lunch at the same time, leaving one (1) float RN on the unit.

Personnel #21 confirmed during an interview conducted 09/16/2020 (1250), that there is only one (1) RN scheduled on the Palo Verde Unit regardless of acuity.

Personnel #19 confirmed during an interview conducted 09/16/2020 (1505), that RN assignments are staffed by patient numbers, and not by acuity. Personnel #19 revealed that the House Supervisor makes rounds to determine what events are occurring on the unit, and to obtain updated information about the patients. Personnel #19 confirmed that the House Supervisor is in charge of completing the acuity, and that staffing assignments are made for the on-coming shift. Additionally, Personnel #19 revealed that there is an acuity score for each patient assigned to the RN and/or LPN, but that there is never a total acuity score totaled to determine if the assignments are equally divided based on the acuity scores.

Personnel #14 confirmed during an interview conducted 09/17/2020 (1104), that the facility uses a computer program to calculate acuity scores, but that assignments are based on the location/blocks of rooms, and not by acuity. Personnel #14 revealed that lunch breaks are thirty (30) minutes, and that the float RN should be covering the units to help out with staffing during that time. Personnel #14 revealed that the Palo Verde Unit only has one (1) RN, and that there has been discussion that perhaps there should be two (2) RN's scheduled. Personnel #14 confirmed, that on 09/16/2020-PM shift, the Juniper Unit had a census of 14, with a total acuity score of 30, and was staffed with 2 RN's and 2 BHT's. Additionally, during the same date/shift, 09/16/2020-PM , the Palo Verde Unit had a census of 12, with a total acuity score of 29, and was staffed with 1 RN and 2 BHT's.

Personnel #3 confirmed during an interview conducted 09/17/2020 (1115), that s/he was not certain what the float RN was doing during observation rounds of the Palo Verde Unit on 09/16/2020 (1240). Additionally, Personnel #3 revealed that the float RN who was observed on the Palo Verde Unit, was the same RN who covered the lunch break for both the RN, and LPN on the Juniper Unit on 09/16/2020 (1320), and that the RN and LPN should not have taken lunch at the same time, leaving the float RN alone on the unit.

Personnel #15 confirmed during an interview conducted 09/17/2020 (1135), that the units are staffed by the location/block of patient rooms, and not by acuity.

Based on a review of the hospital's policy/procedure, medical records, and interview, it was determined that hospital failed to require that nursing care was directed by a registered nurse (RN) as evidenced by the failure to require that all patients transferred out of the facility obtain a physician's order; and document the transferring hospital information. This deficient practice poses a risk to the health and safety of the patients when staff fail to document the need for continuity of care.

Findings include:

Policy titled "Patient Transfer and Transport (Policystat ID: 8162083; 06/2020), revealed: "...The need for medical treatment/assessment will be determined by the attending and/or consulting medical physician. In the event of an emergency the RN will contact the attending/covering physician or designee for an order to transfer but will not delay emergency care and services...physician will provide the transfer order which includes rationale for transfer (i.e. x-ray, consultation, etc.)...destination and mode of transfer...Memorandum of Transfer (MOT) Form will be completed in all patient transfer or transport situations whether planned or emergency...."

Medical Record Review conducted 09/16/2020 revealed the following:

1.Patient #26 was transferred on 07/28/2020 (1330). No physician order to transfer the patient was located in the medical record, and no RN assessment was located upon the patient's return to the facility, as required per facility policy;

2. Patient #28 was transferred a total of three (3) times on 07/28/2020 (2000), 07/31/2020 (1030), and 07/31/2020 (2133). The Memorandum of Transfer forms were incomplete and no physician order was documented in the medical record for the transfers on 07/28/2020 (2000) and 07/31/2020 (2133), as required per facility policy;

3. Patient #30 was transferred on 08/17/2020 (1711). The Memorandum of Transfer form had three (3) sections that were incomplete, and not per facility policy.

Employee #14 confirmed during an interview conducted on 09/19/2020, that there were no physician transfer orders documented in Patient #26 and Patient #28's medical records. Additionally, Employee #14 revealed the Memorandum of Transfer forms were incomplete.

Based on review of the facility's policy/procedure, medical records, and staff interview, it was determined that the facility failed to ensure that nursing personnel documented accurate patient observations, to include special precautions in the medical record. This deficient practice poses a potential risk to the health and safety of patients when physician ordered special precautions are not monitored accurately.

Findings include:

Policy titled "Levels of Observation and Special Precautions" (PolicyStat ID: 7319043; 01/2020), requires: "...staff will observe and document on the Patient Observation Record Q 15 minutes...Special Precautions...1...physician may order a specific precaution level based on their evaluation for: Aggression, Suicide, Elopement, Sexual Acting Out...."

Medical record review conducted on 09/16/2020, revealed that fourteen (14) of thirty-one (31) records lacked documentation of special precautions as ordered by the physician.

Employee #14 confirmed during an interview conducted on 09/17/2020 (1010), that there was no special precautions documentation in fourteen (14) of thirty-one (31) medical records as ordered by the physician.

Based on review of the hospital's policy/procedure, documents, and interviews, it was determined that the hospital failed to require that medications stored in a refrigerator, were maintained at the correct temperature per manufacturer recommendations. This deficient practice poses a risk to the health and safety of the patient(s), when staff fail to document the temperature of the medication refrigerator, ensuring that the medications have not been compromised.

Findings include:

Policy titled "Storage of Medications" (#8278527; 08/2020), revealed: "...medications will be stored in a manner consistent with State and Federal law...Refrigerators...medications requiring refrigeration will be stored in a refrigerator...maintained by the medication nurse at a temperature between 36 and 46 degrees Fahrenheit...temperature of each refrigerator on each nursing unit will be recorded by nursing personnel on a daily basis on a log sheet...refrigerator temperatures will also be monitoring by...pharmacy during it's monthly unit inspections...."

Document form titled "Medication Refrigerator Temperature Log" (no form #, or revised date) requires: "...place temperature and initials in the box that corresponds with the day of the month for temperature checks...temperatures is to be checked twice each day...."

Documents titled "Medication Refrigerator Temperature Log", revealed the following:

Mesquite Unit

i. August 2020 (31 days): A total of fourteen (14) AM temperatures with no documented readings, and eight (8) PM temperatures with no documented readings;

ii. September 2020 (1-15 days): A total of fourteen (14) AM temperatures with no documented readings, and eight (8) PM temperatures with no documented readings.

Juniper Unit

i. May 2020 (31 days): A total of seventeen (17) AM temperatures with no documented readings, and nine (9) PM temperatures with no documented readings;

ii. June 2020 (30 days): A total of thirteen (13) AM temperatures with no documented readings, and six (6) PM temperatures with no documented readings;

iii. July 2020 (31 days): A total of six (6) AM temperatures with no documented readings, and three (3) PM temperatures with no documented readings;

iv. September (1-15 days): No missed readings.

Palo Verde Unit

i. May 2020 (31 days): A total of twenty-three (23) AM temperatures with no documented readings, and six (6) PM temperatures with no documented readings;

ii. June 2020 (30 days): A total of twenty-three (23) AM temperatures with no documented readings, and twelve (12) PM temperatures with no documented readings;

iii. July 2020 (31 days): A total of twenty (20) AM temperatures with no documented readings, and twenty (20) PM temperatures with no documented readings;

iv. August 2020 (31 days): A total of twenty (20) AM temperatures with no documented readings, and eight (8) PM temperatures with no documented readings;

v. September (1-15 days): A total of eight (8) AM temperatures with no documented readings, and four (4) PM temperatures with no documented readings.

Personnel #21 confirmed during an interview conducted 09/16/2020 (1240), that the medication refrigerator should have temperature checks documented twice a day, on both the AM and PM shifts. Additionally, Personnel #21 revealed that it is the responsibility of the nurse to document the temperatures.

Personnel #3 confirmed during an interview conducted 09/16/2020 (1600), that medication refrigerator temperature checks should be done on both the AM and PM shifts by nursing personnel, and recorded on the temperature log. Additionally, Personnel #3 revealed that the medication refrigerator temperature logs reviewed for the Mesquite, Juniper, and Palo Verde units had missing temperature readings.

Based on review of the hospital's specimen refrigerator temperature logs, and interview, it was determined that the hospital failed to require that certain specimens collected at the hospital, were stored in a refrigerator with monitored temperatures. This deficient practice poses a risk to the health and safety of the patient(s), when specimens collected, and pending laboratory pick-up, are not stored in a properly temperature controlled refrigerator, with the potential to have the specimen(s) result as inaccurate when tested.

Findings include:

Document form titled "PLAB Specimen Refrigerator Temperature Log" (no form #, or revised date) requires: "...place temperature and initials in the box that corresponds with the day of the month for temperature checks...temperatures is to be checked twice each day...."

Documents titled "PLAB Specimen Refrigerator Temperature Log", revealed the following:

Mesquite Unit

i. August 2020 (31 days): A total of twenty-eight (28) AM temperatures with no documented readings, and ten (10) PM temperatures with no documented readings;

ii. September 2020 (1-15 days): A total of eleven (11) AM temperatures with no documented readings, and six (6) PM temperatures with no documented readings.

Palo Verde Unit

i. June 2020 (30 days): A total of sixteen (16) AM temperatures with no documented readings, and nineteen (19) PM temperatures with no documented readings;

ii. July 2020 (31 days): A total of twenty (20) AM temperatures with no documented readings, and nineteen (19) PM temperatures with no documented readings;

iii. No August log provided;

ii. September 2020 (1-15 days): AM with all temperatures documented, and six (6) PM temperatures with no documented readings.

The surveyor requested a policy/procedure for monitoring the temperatures of the specimen refrigerators on 09/16/2020, and none was provided.

Personnel #7 confirmed during an interview conducted 09/17/2020 (1315), that the facility had no policy/procedure specific to monitoring the temperatures of the specimen refrigerators.

Based on review of the facilities policies/procedures, contract list, observations on tour, and interviews, it was determined that the facility failed to appoint a full-time employee who serves as director of the food and dietetic services. This deficient practice poses a potential risk to the health and safety of the patients, when the facility fails to have an employee given the authority and responsibility by the hospital's governing body and medical staff, who is qualified by experience or training the responsibility for daily management of the dietary services monitoring safe practices for food handling, emergency food supplies, maintaining essential records, quality of nutrition services and performance improvement.

Findings include:

Policy titled "Dietary Services" reveals "...The hospital will ensure provision of patient specific nutritional services through dietitian services for meal planning and assessments, processes that address diet orders and meal delivery, staff training for all processes and a contract with a food services provider...All Registered Nurses and Behavioral Health Technicians shall receive training related to the Dietary Services processes...."

The facility's contract list revealed a contract with Healthcare Services Group, Inc. (HCSG). The contract was requested on 09/16/2020, however it was not provided.

Observations made during tour of the facility on 09/16/2020 revealed that the Dietitian and all employees working in the dietary services, including the Dietary Director were contracted employees.

Employee #1 confirmed in an interview on 09/16/2020 that all dietary services, including Director of Dietary, are contracted through HCSG.

Contracted Employee #10 confirmed in an interview on 09/16/2020 that s/he is the Director of Dietary at the facility, and that s/he is employed by HCSG and is not employed by the facility.

Based on review of the facility's policies/procedures, documents, and interviews, it was determined that the facility failed to create a Utilization Review (UR) Committee consisting of two or more practitioners to carry out the UR function. This deficient practice poses a potential risk to the health and safety of the patients when the medical necessity of admission, duration of hospital stays, or the professional services furnished are not examined or documented.

Findings include:

Policy titled "Utilization Management Plan" last approved on 04/2020, reveals "...The...Utilization Review Committee evaluate and monitor services to patients provided by medical and other professional staff...The activities include evaluation of: Medical necessity of admissions and continued stay...Appropriateness of patient care settings...Level, intensity and variety of services provided...Discharge planning...Coordination of resources and benefits, including high-risk care...Use of resources to achieve maximum benefit from treatment...The organization of the utilization management processes consists of two elements: a) the Utilization Management staff, and b) the Utilization Review Committee, which is established as a committee of the medical staff. The Medical Director provides consulting oversight to the utilization management staff...and is a member of the Utilization Review Committee...Meetings are held at least quarterly or more frequently as scheduled by the Chairperson. A quorum is...defined as a simple majority of the total of the committee members...."

Utilization Review meeting minutes were requested on 09/17/2020, however none were provided.

Employee #26 confirmed in an interview on 09/17/2020 that s/he did not participate in the development of the Utilization Management Plan. There have been no meetings yet, therefore no meeting minutes.

Provider #1 confirmed in an interview on 09/17/2020 that there is no committee so there are no meeting minutes.

Based on review of the facility's policies/procedures, hospital documents, observations on tour, and interviews, it was determined that the hospital failed to require that:

1. expired supplies, used for patient care, were discarded and not used after the expiration date. This deficient practice poses a potential risk to the health and safety of the patients, including risk for infection, negative outcomes, and/or false laboratory testing when the facility cannot ensure that expired supplies are being discarded and are not being used for patient care;

2. the emergency cart checks were being completed on a daily basis. This deficient practice poses a potential risk to the health and safety of the patients, when the facility fails to monitor the code cart for working emergency equipment that is used to assist with an emergent situation, including a "Code Blue";

3. annual preventive maintenance (PM) checks were completed on equipment used for patient care. This deficient practice poses a risk to the health and safety of the patient(s), when equipment used for emergency care, or obtaining patient cardiac rhythms are not serviced ensuring the equipment functions properly.

Findings include:

1.
Observations on tour conducted 09/15/2020 through 09/17/2020, throughout the hospital's premises revealed the following:

A total of five hundred and sixty-six (566) expired supplies, with outdates ranging from 10/2017 through 09/11/2020, were found. The expired supplies were collected and given to Employee #1.

Policy for Expired Supplies was requested on 09/17/2020, and no policy was provided.

Employee #3, Employee #7, and Employee #14 confirmed during observations on tour conducted 09/15/2020 through 09/16/2020, throughout the hospital premises, that the identified supplies were expired.

2.
Policy titled "Code Blue" revealed: "...The Code Blue is the mechanism to provide rapid emergency assistance to the person in cardiopulmonary crisis ...Transport the Emergency equipment to include, Suctioning machine and supplies...O2, and AED to the patient...Emergency Cart Checks...Emergency Cars will be checked daily...."

Hospital document titled "Code Cart Checklist" revealed that the checklist lists: Day 1 through Day 31, AED Charged with Pads (Y/N), Code Cart Locked, Suction Machine Working (Y/N), Oxygen Level Greater than 1000ps {sic}, Nurse Initials, and Comments.

Hospital document titled "Emergency Cart Checklist" revealed that the checklist lists: Day 1 through Day 31, AED Charged with Pads (Y/N), Code Cart Locked, Suction Machine Working (Y/N), Oxygen Level Greater than 1000ps {sic}, Staff Initials, and If No what did you do to resolve issue?

Hospital document titled "Code Cart Checklist - Month: June Unit: Mesquite" revealed that 16 out of 30 cart checks were completed.

Hospital document titled "Emergency Cart Checklist - Month: July Unit: Mesquite" revealed that 10 out of 31 cart checks were completed.

Hospital document titled "Emergency Cart Checklist - Month: August Unit: Mesquite" revealed that 17 out of 31 cart checks were completed. Additionally, the suction machine was identified as not working and the oxygen level was below 1000ps {sic} on 08/06/2020, 08/07/2020, and on 08/09/2020, however no interventions were performed to correct the issues until 08/09/2020.

Hospital document titled "Emergency Cart Checklist - Month: September Unit: Mesquite" revealed that 7 out of 14 cart checks were completed prior to the survey on 09/15/2020.

Observations on tour conducted 09/15/2020, on the Mesquite unit revealed that the emergency cart check log book was not being completed on a daily basis.

Employee #3 confirmed during an interview conducted on 09/15/2020, that the emergency carts should be checked on a daily basis and that the logs were not complete.

3.
Policy titled "Medical Equipment Management Plan" (#7998146; 05/2020), revealed: "...focuses on the process to effectively manage medical equipment...and establishes proactive risk assessments to reduce the risk of injury...addresses...inspection...of medical equipment...Goals...monitor all service and preventative maintenance inspections to assure that medical equipment is maintained and serviced so equipment continues to function properly...Governing Body has ultimate authority and responsibility for the Medical Equipment Management Plan...Chief Executive Officer (CEO) shall appoint the Director of Nursing who will be responsible for ensuring compliance with the Medical Equipment Plan...all medical equipment listed in the inventory will be inspected and tested in accordance with the...manufacture's recommendations...Haven Hospitals must maintain a current, compliant Bio-Medical Engineering vendor responsible to required semi-annual, and annual testing...."

Observations on tour conducted 09/16/2020, with Personnel #3, and Personnel #7, revealed the following:

Palo Verde Unit

i. Suction Machine (on top of Emergency Cart), PM sticker "Next Due - 12/2019);
ii. Burdick Electrocardiogram (ECG), Biomed #1043076, no PM sticker.

Juniper Unit

i. Burdick ECG, Biomed #1043009, no PM sticker.

Personnel #3 and Personnel #7, both confirmed during combined interviews conducted 09/16/2020 (1240 -1505), that the identified equipment (suction machine, ECG machines), had no documented evidence of current preventive maintenance being completed.

Based on review of the hospital's policy/procedure, document, medical record and interviews, it was determined that the hospital failed to require that the nursing staff notify the Donor Network following the death of Patient #27. This deficient practice has a potential risk, for decreasing the number of potential donors available to the Donor Network.

Findings include:

Policy titled "Death-Natural Death of a Patient" (PolicyStat ID: 7319043; 01/2020), revealed: "...The DON/designee shall notify contracted organ donor procurement agency...."

Document titled "Senior Horizons, Vendor Contracts" (no date), revealed that the Donor Network of Arizona was listed on the hospital's contract list.

Medical record review conducted 09/16/2020, revealed no documented evidence that the Donor Network of Arizona was notified after the death of Patient #27, occurring on 12/09/2019.

Employee #2 and Employee #13 confirmed during individual interviews conducted on 09/16/2020 (1405), that the Donor Network of Arizona should have been notified of the patient's death, and that documentation was lacking per the facility's policies and procedures.
.

Based on observation, interview and facility record review the facility failed to develop Emergency Preparedness policy and procedures based on the community risk assessments prior to developing the facility's emergency plan. Failure to develop Emergency Plans based on community risk assessments may cause harm to the patients and staff during an emergency.

Findings include:

On September 17, 2020, while reviewing the facility's Emergency Plan with the Director of Quality, the facility failed to provide a community based risk assessment as required by CRF 494.62.

During the exit conference on September 17, 2020, the above finding was again acknowledged by the Director of Quality.

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 risk assessments may cause harm to the patients and staff during an emergency.

Findings include:

On September 17, 2020, while reviewing the facility Emergency Plan, with the Director of Quality, their plan provided, only used the facility assessment and did not include a community based all hazards risk assessment. CRF 494.62 requires both facility and community hazard assessments to develop the policy and procedures.

During the exit conference on August 5, 2020, the above finding was again acknowledged by the Director of Quality.