HospitalInspections.org

Based on the review of policies and procedures, documents, and interviews it was determined the hospital failed to ensure that automated external defibrillators (AEDs) were being maintained according to the manufacturer's recommendations. This deficient practice poses a potential risk to the health and safety of patients when this life-saving device is not maintained.

Findings include:

The policy titled "Maintenance of Equipment and Frequency" revealed: "...Policy: All equipment utilized for the provision of health care shall be inspected at least annually; calibrated as necessary and regularly maintained to ensure accurate test results ...Protocols: The following items will be inspected, serviced as necessary and calibrated as per manufacturer and/or established regulations governing equipment utilization ...AED ...Maintenance/Inspections Frequency ...Annually ...Responsible Staff ...The Back Office personnel and/or Supervisor shall be responsible for ensuring {sic} that all equipment is operating as per manufacturer's specifications and/or standard regulations. Documentation of equipment inspections will be completed by the Bio-Engineer ...."

Hospital document titled "Monthly Battery AED Check" revealed that the date documented on the Monthly Batter AED Check sheet was dated 09/01/2020.

The hospital document titled "Administrator's Guide" revealed: "...Maintaining the Unit - Inspect frequently, as necessary. - Check for the green check showing that the unit is ready to use. - Test periodically. Verify electrodes are within their expiration date. - Verify batteries are within their expiration date. - Verify that electrodes are pre-connected to the input connector. - Verify supplies are available for use (razor, masks, gloves, extra batteries.) ..."

Observation on tour conducted on 01/04/2022 revealed the AED located in the hall by pharmacy had a Monthly Battery AED Check form located with the AED and the last entry was documented as 09/01/2020. Tour on 01/05/2022 revealed the AED located in physical therapy did not have a Monthly Battery AED Check form with the AED, however, an Administrator's Guide was located with the AED describing the maintenance to be completed periodically for the unit.

Employee #2 confirmed during an interview conducted on 01/04/2022, that the last monthly check for the AED located in the hall by pharmacy was documented as being completed on 09/01/2020.

Employee #5 confirmed during an interview conducted on 01/05/2022, that there was no monthly check sheet for the AED located in the physical therapy area and s/he does not know when the AED was last checked.

Based on the review of Hospital Bylaws, Medical Staff Bylaws, Medical Staff Rules and Regulations, and staff interview, the Department determined the Governing Body failed to ensure the Hospital Bylaws and Medical Staff Rules and Regulations were reviewed and updated every three (3) years. This deficient practice could pose a potential risk for patients to not receive quality care according to current Hospital, State, and Federal Standards.

Findings include:

A review of the hospital document titled "Amended and Restated Bylaws of Community Hospital Association, Inc." revealed: " ...Article Fourteen Amendments to Bylaws: 14.1 ...These Bylaws shall be reviewed in total by the Board of Directors no less frequently than every two (2) years ...." Further review of the Hospital Bylaws revealed a revision date of 05/01/2018.

A review of the facility's Medical Staff Rules and Regulations revealed a revision date of 06/23/2008.

A review of the hospital document titled "Medical Staff Bylaws" dated 07/23/2019, revealed: " ...Article 20- Rules and Regulations ...The MEC (Medical Executive Board) shall adopt such Rules and Regulations necessary to comply with the general principles found in these Bylaws, subject to the approval of the Board. Such Rules and Regulations shall be part of these Bylaws, except they may be amended or appealed at regular or special Medical Staff meetings at which a quorum is present, by a majority vote of the Medical Staff present. Amendments shall become effective when approved by the Board ...."

Employee #3 Chief Nursing Officer (CNO) confirmed during an interview on 01/06/2022, that the Hospital Bylaws reviewed on 05/01/2018 are the hospital's most current bylaws. Employee #3 confirmed that the facility's Medical Staff Rules and Regulations were last revised on 06/23/2008.

Based on a tour of the hospital, hospital policy, and staff interview, the Department determined that the hospital failed to store medications in a secure, locked location that is inaccessible to unauthorized persons. This deficient practice poses the potential risk of medications for patient use being tampered with, diverted, or accessed by unauthorized persons.

Findings include:

A hospital tour conducted on 01/04/2022 revealed blue bins hanging in a nurses' station next to a photocopy machine. Inside one bin labeled "109," were two (2) bottles containing Topamax tablets. In another bin labeled "outpatient," there was a bag containing two (2) ampules of Cefazolin and two (2) 100ml bags of normal saline.

The policy titled "Medication Area Storage and Inspections," approved 12/2021, revealed: "...Lockable storage units are to be provided for each storage area ...Drugs to be kept in a locked area when unattended and are to be inaccessible to unauthorized individuals ...."

Employee #28 confirmed in an interview conducted on 01/04/2022, that this is where medications for outpatients come in for infusions, and patient home medications are kept.

Employee #8 confirmed in an interview conducted on 01/04/2022, that medications are placed in those bins because there is no space for them in the Omnicell they use for Acute patients.

Based on the review of policies and procedures, medical record review and staff interviews, the Department determined the Hospital failed to ensure nutrition assessments were being performed when ordered. The deficient practice could pose a risk to patients ' health and nutrition by not identifying nutritional needs and deficits.

Findings include:

The policy titled "Dietary Consult, 12/2019" revealed: " ...Within 24 hours of admission, Nursing shall review patient ' s history and diet order to determine if a Dietary Consult is required ...If a patient requires a consult, the physician or nurse will write an order and contact the Registered Dietitian to request a consult ...Within 24 hours the Dietitian will see the patient one to one ...The Dietitian will document the initial evaluation, assessments, progress notes, and other recommendations in the Nutritional Assessment section in the patient ' s chart...."

The policy titled "Nutrition Assessment and Reassessment, #10276205, 08/2021" revealed: " ...Each patient who is identified to be at nutrition risk will be seen by the Dietitian ...Patients who are hospitalized for more than 7 days after the initial screening will be re-screened then and every 7 days, as above ...."

The policy titled " Swing Bed: Nutritional Services, #10071748, 07/2021" revealed: " ...A nutritional screening will be performed as part of the admission assessment with a more in-depth nutritional assessment for patients determined to be a high risk ... High-risk patients will be identified and reassessed at least weekly ...The nursing personnel and physicians may request a reassessment at any time but a reassessment will be completed whenever the patient has experienced significant weight loss, had a significant change in eating habits, or has lab work indicative of nutritional concerns ...."

A review of twenty (20) medical records was performed on 01/06/2022 which revealed one (1) patient, Patient #16 had a nutritional assessment ordered that was not completed by the dietitian. Further review of the medical records revealed, Patient #13 did not have an initial nutritional evaluation at admission or a nutritional assessment performed. A review of the provider orders for Patient #13 revealed orders was written on 11/13/2021 for a "heart-healthy diet" and "nutrition consult/assessment".

Employee #9, Registered Nurse (RN) confirmed during an interview on 01/06/2022 that there have been no patient nutritional assessments performed since 11/08/2021.

Employee #23, Interim Director of Acute Care, confirmed during an interview on 01/06/2022 that there has not been a dietitian available since 11/08/2021, and therefore no nutrition consults or assessments have been performed by the dietitian.

Based on a review of medical records, facility policies and procedures, and interview the Department determined that the hospital failed to ensure that patients admitted to the swing bed program were informed of their admission and patient rights. This deficient practice poses the risk of a patient is unaware of their rights during their stay in the swing bed facility.

Findings include:

The policy titled "Swing Bed: Admission, Transfer, and Discharge Rights" revealed: "...Each patient will receive appropriate documentation detailing the patient's rights concerning admission, transfer, and discharge from the Swing Bed Program ...Admissions to WCH Swing Bed will ...the patient will sign an acknowledgment of the receipt of the document and that acknowledgment will be made a part of the permanent medical (sic)...."

The policy titled "Swing Bed: Patient Rights" revealed: "...Upon admission to the Swing Bed Program, each patient will receive a copy of the "Patient's Rights". A signed acknowledgment of the patient's receipt of the Patient's Rights document will be made a part of the permanent medical record ...."

A review of two (2) patient records in the hospital's swing bed program revealed that there was no signed acknowledgment of admission nor of patient rights.

Employee #9 confirmed during an interview conducted on 01/06/2022, that the patient records did not contain a signature upon admission or a signed notification of patient rights.

Employee #3 confirmed in an interview on 01/06/2022, that there was no consent for admission separate for swing bed patients.

Based on observation, review of policies and procedures, hospital documents, Center for Disease Prevention and Control (CDC) guidelines, and staff interviews, the Department determined the Hospital failed to ensure individuals entering the facility were being screened for COVID-19. The deficient practice poses a risk to the health and safety of patients and staff by possible exposure to infectious and communicable diseases.

Findings include:

Observations on 01/04/2022 revealed signs on the doors to the entrances of the main lobby and Emergency Department stating masks were required at all times while in the facility. Further observation revealed no signs posted regarding signs and symptoms of COVID-19 on the doors to the Main Entrance and Emergency Department (ED) Entrance. Upon entering the lobby, it was observed that no active screening for COVID-19 was being performed on individuals as they entered the facility at the main lobby or the emergency department entrance. No COVID-19 screening was performed on the survey team upon entering the facility. No signs were observed in the main lobby regarding signs and symptoms of COVID-19 and visitor restriction if symptoms were present.

Observation on 01/05/2022 revealed signs on entrance doors stating masks required at all times while in the facility. Further observation revealed no signs posted regarding signs and symptoms of COVID-19 at the entrances. Upon entering the lobby, no screening for COVID-19 was being performed on individuals entering the facility, including the survey team. No signs were observed in the main lobby regarding signs and symptoms of COVID-19 and visitor restriction if symptoms were present.

The policy titled "COVID-19 (2019 Novel Coronavirus), #10158856, 07/2021" revealed: " ...Visitors with fever, cough, vomiting or diarrhea should not visit WCH (Wickenburg Community Hospital) unless they are seeking medical care. If these symptoms are present and you need medical attention, we ask that you put on a mask immediately upon entering the building to protect other patients, visitors, and health care workers ...."

The hospital document titled "7-15-2021: Revision to Patient Visitor Practice on the Acute Care Unit" revealed: " ...All visitors must attest to being free of COVID-19 symptoms for 10 days or greater ...."

A review of the hospital's completed "CMS COVID-19 Focused Infection Control Survey Tool'' dated 01/05/2022, revealed the facility stated it had signage posted at the facility entrances with visitation restrictions and screening procedures. The facility also answered affirmatively that the facility has a screening process for those entering the facility (patients and visitors) to mitigate the risk of COVID-19 exposure (for example exposure to COVID-19 screening questions and assessment of symptoms/illness); the facility also stated on the survey tool that the facility utilizes the most current CDC protocols and guidelines.

Review of the current Center for Disease Prevention and Control (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) dated 11/06/2020 revealed facilities should have a screening process to assess for signs/symptoms consistent with COVID-19 and for exposure to others with known or suspected COVID-19. CDC recommends options for screening symptoms that include but are not limited to screening questions with an assessment of illness, self-monitored pre-arrival temperature checks with the reported absence of fever and symptoms, and facility-monitored temperature checks upon arrival. Although screening for symptoms will not identify asymptomatic or pre-symptomatic individuals with SARS-CoV-2 infection, symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented.

Employee #6 (Infection Prevention Practitioner) confirmed during an interview on 01/05/2022 that the facility is not screening individuals for COVID-19 when they enter the facility. Employee #6 stated screenings are not being done now in accordance with the latest CDC guidelines. Employee #6 stated masks are required and there are signs posted at the entrances and throughout the hospital stating masks are required at all times.

Based on the review of policies and procedures, observations on tour, and interviews, the Hospital failed to ensure:

1. That kitchen staff were wearing hair coverings or nets while working in the kitchen. This deficient practice poses a potential risk of bacteria from an employee's hair coming into contact with food, clean and sanitized equipment, and utensils.

2. That ice machines were cleaned and descaled. This deficient practice poses a potential risk to the health and safety of patients, staff, and visitors of potentially dangerous germs infecting the ice supply and causing them to become sick.

3. That medical supplies used for patient care were not expired. This deficient practice poses a potential risk for the health and safety of the patients, including risk for infection, negative outcomes, and or false laboratory testing when the hospital cannot ensure that expired supplies are being discarded, and are not being used for patient care.

Findings include:

1.
The policy titled "Dress Code" revealed: "...Policy: Food Service employees will dress for work in clothing suitable to the image and sanitation needs of the department ...Procedure ...Hair covering - For hair shorter than 1 ½ inch - must wear a hair net or ball cap. For hair longer than 1 ½ inch - hair must be pulled back and secured so there is no possibility of hair contaminating food ...."

The policy titled "Food Handling" revealed: "...Employee Health ...5 ...Hair nets or caps are to be worn in food preparation and service areas ...."

Observation conducted on 01/04/2022 revealed that two (2) of three (3) employees were not wearing hairnets in the kitchen.

Employee #11 confirmed during an interview conducted on 01/04/2022, that all employees should be wearing hairnets in the kitchen.

2.
The policy titled "Equipment Management" revealed: "...Procedure ...4. Ice machines in the Snack Shack, ED, and Acute Care will be cleaned, sanitized daily by Dietary Staff. 5. The machines will be maintained free of rust, mold, and lime and other contaminates {sic} ...."

Hospital document titled "Ice Machine" revealed:
Acute Care: 06/18/2021, cleaned, changed filter
Surgery/Pre-Op: 06/18/2021, descaled, sanitized, and changed the filter
Acute Care/Nursing Station: 09/12/2021, Descaled and sanitized
ED: 05/31/2021, descaled and sanitized.

Observation conducted on 01/04/2022, revealed that the ice machine in the surgery/pre-op had limescale on the drain and dispenser. The right-side panel fell off of the ice machine.

Observation conducted on 01/06/2022, revealed that the ice machine in the ED had limescale on the drain and dispenser. The dispenser also had a black substance around the opening of the dispenser.

Employee #4 confirmed during an interview conducted on 01/06/2022, that there was limescale present on the ice machine and that the hospital's water was hard water.

3.
During facility tours conducted on 01/04/2022, and 01/06/2022, the following expired (exp) supplies were found:

Lab:
9ml red top tubes, exp 12/9/2021 x4

In code cart on the acute floor:
Smart site extension set, exp 11/13/2021 x2
8ml vacuette red top tube, exp 10/23/2021 x1
2.7ml light blue top vacutainer, exp 10/31/2021 x1
Suction catheter 12Fr, exp 11/10/2021 x1
Adult Colorimetric CO2 detector, exp 12/8/2021 x2
Smart site extension set, 11/12/2021 x2

Nurses station in drawers in acute care:
Transystem Transport swab, exp 12/31/2021 x8

Clean supply in the acute unit:
BD bactec Blood culture bottle 40ml exp 10/21/2021 x1

In the operating room (OR):
Chemical indicator inside stryker scope sleeve sterilization pouch exp 01/01/2021 x1

Anesthesia Cart in OR:
5.5mm Maillinckrodt endotracheal tube (ETT), exp 4/26/2021 x1
6.0mm Mallinckrodt ETT, exp 05/31/2021 x2
6.0mm Mallinckrodt ETT, exp 03/17/2021 x1
5.0mm Mallinckrodt ETT, exp 05/24/2021 x2
8.5mm Mallinckrodt ETT, exp 03/01/2021 x1
Tegaderm Film 6cm x 7cm exp 12/07/2021 x13
Pink top 6ml Vacuette exp 06/12/2021 x4
Purple top 3ml x1 vacuette exp 07/11/2021 x1
Red top 9ml vacuette, exp 07/07/2021 x1
BD Connecta stopcock, exp 09/31/2021 x5

Emergency Department (ED):
Xeroform occlusive gauze patch 4"x4", exp 10/31/2021 x20
PICC/CVC Securement 3.5"x4.5in, exp 09/27/2021 x18

Policy titled "Discarding of Expired Supplies" revealed: "...All dated materials will be checked for expired date when supplies are restocked on a weekly basis. If supplies are found to be expired they will be disposed of according to manufactures suggestion ...."

Employee #7confirmed during an interview conducted on 01/04/2022, that the listed supplies in the acute units were expired.

Employee #29 confirmed during an interview conducted on 01/04/2022, that the listed supplies in the OR, pre-operative, and postoperative areas were expired.

Employee #4 confirmed during an interview conducted on 01/06/2022, that the listed supplies in the ED were expired.

Based on the review of policies and procedures, documents, medical records, and interviews, the Hospital failed to ensure that the hospital followed its own policies and procedures related to complaints and grievances. This deficient practice poses a potential risk to the health and safety of patients when a potential system or individual performance problems may not be addressed.

Findings include:

The policy titled "Patient Concern, Complaint and Grievance Resolution Process" revealed: "...Policy: The purpose of these guidelines is to establish mechanisms for concerns, complaints and grievances regarding the plan of care, treatment, or ethical issues that arise for patients being served by Wickenburg Community Hospital (WCH)...All complaints MUST be submitted into the Quality Calendar database within 24 hours of the event ...Procedure ...Complaint Process: A. Patients or representatives, family members, or visitors may voice a complaint at any time. Verbal concerns that are unable to be resolved by staff present and require the intervention of a departmental supervisor/manager or director will be documented in Quality Calendar ...B. Written complaints will be required to be entered into Quality Calendar ...then forwarded on to the Quality/Risk Manager within 24 hours. The Quality/Risk Manager will forward the written complaint event to the Patient Experience Coordinator, departmental supervisor, or manager for investigation and resolution. The supervisor or manager has 72 hours in which to investigate and attempt to resolve the complaint. Grievance Process: A. Written grievances will be required to be entered into Quality Calendar by the person receiving the written grievance, then forwarded on to the Quality/Risk Manager within 24 hours ...The supervisor or manager has 72 hours in which to investigate and attempt to resolve the complaint. B. For ALL Patients, an acknowledgment letter ...is generated by the director or chief officer within 7 business days of the grievance being filed by the patient or representative. The letter states the grievance has been received, is being investigated ...The director or chief officer will provide ongoing contact to the patient or representative as needed during the investigation process until the grievance is resolved. D. The grievance, its investigation, and proposed resolution will need to be completed within 5 business days ...F. When a resolution is reached by WCH Patient Relations Committee, the disposition of the matter by the committee is communicated to the complainant in written form ...G. For CMS complaints and grievances, the patient or representative will be notified with an Acknowledgement Letter ...within 7 business days of receiving the complaint/grievance. The final grievance resolution must occur within ninety (90) days of the grievance being received by the manager/director or chief officer in writing (Closure Letter...) ..."

Hospital document titled "Quality Calendar" revealed:

Patient #2 was seen on 08/03/2017, in the Emergency Department. The patient complained to the hospital administrator, Employee #27 - Former Chief Executive Officer (CEO), and the complaint was never entered into the Quality Calendar system.

Patient #21 - Complaint/grievance entered on 08/03/2021, into the Quality Calendar. On 08/03/2021, Quality called the patient and had a discussion with the patient. The complaint/grievance was investigated on 08/11/2021, by the Manager over admitting. There was no documentation of any letter (acknowledgment, ongoing, or closure) being sent to the complainant.

Patient #22 - Complaint/grievance entered on 10/21/2021, into the Quality Calendar. The complaint/grievance was sent to the Emergency Manager to investigate and then to the service provider. There was no documentation of any letter (acknowledgment, ongoing, or closure) being sent to the complainant.

Medical records were reviewed for Patient #2, Patient #21, and Patient #22.

Employee #6 confirmed during an interview conducted on 01/05/2022, that the Quality Calendar is the hospital's system where complaints and grievances are entered, investigated, verified, evaluated, and then tracked and trended. There were no letters (acknowledgment, ongoing, or closure) sent to Patient #21 or Patient #22 documented in the Quality Calendar. Employee #6 revealed that Patient #2's complaint/grievance was never entered into the Quality Calendar. Patient #2 went directly to Employee #27 - Former Chief Executive Officer (CEO) who was handling Patient #2's s complaint. Employee #6 informed Employee #27 that Patient #2's complaint/grievance needed to be put in the hospital's complaint/grievance system, however, Employee #27 stated that s/he would take care of Patient #2's complaint/grievance and that Employee #6 did not need to be involved.

Based on the review of medical records, facility policies and procedures, and interview the Department determined that the hospital failed to ensure that patients admitted to the swing bed program had documentation that they were informed of patient rights. This deficient practice poses the risk of a patient is unaware of their rights during their stay in the swing bed facility.

Findings include:

The policy titled "Swing Bed: Patient Rights" revealed: "...Upon admission to the Swing Bed Program, each patient will receive a copy of the "Patient's Rights". A signed acknowledgment of the patient ' s receipt of the Patient's Rights document will be made a part of the permanent medical record ...."

A review of two (2) patient records in the hospital's swing bed program revealed that there was no signed acknowledgment of patient rights in two (2) out of two (2) records.

Employee #9 confirmed during an interview conducted on 01/06/2022, that the patient records did not contain a signed notification of patient rights.

Based on the review of medical records, facility policies and procedures, and interviews, the Department determined that the hospital failed to ensure that patients admitted to the swing bed program were informed of their admission rights. This deficient practice poses the risk of a patient being unaware of rights related to being admitted, discharged, or transferred during their stay in the swing bed facility.

Findings include:

The policy titled "Swing Bed: Admission, Transfer, and Discharge Rights" revealed: "...Each patient will receive appropriate documentation detailing the patient's rights concerning admission, transfer, and discharge from the Swing Bed Program...Admissions to WCH Swing Bed will...the patient will sign an acknowledgment of the receipt of the document and that acknowledgment will be made a part of the permanent medical {sic}...."

A review of two (2) patient records in the hospital's swing bed program revealed that there were no signed acknowledgments of admission rights.

Employee #9 confirmed during an interview conducted on 01/06/2022, that the patient records did not contain a signature upon admission.

Employee #3 confirmed in an interview on 01/06/2022, that there was no consent for admission separate for swing bed patients.

Based on the review of medical records, hospital policy, and interviews, the Department determined the hospital failed to conduct a complete admission assessment on swing bed patients in the hospital. The deficient practice poses the potential risk of inadequate care plans for the swing bed patients, and patient needs not being met.

Findings include:

The policy titled "Swing Bed: Comprehensive Admission Assessment" revealed: "...A comprehensive assessment as outlined in the approved assessment guidelines and form will be completed for each Swing Bed patient to determine his or her functional capacity ...This assessment will include ...description of the patient's capability to perform daily life functions ...physical and mental functional status ...sensory and physical impairments ... dental condition ...nutritional status and requirements ...skin condition and wound care ...mental and psychosocial status ...potential for discharge ...potential for rehabilitation ...cognitive status ...drug therapy ...."

A review of two (2) swing bed medical records revealed incomplete admission assessments. Missing components of the admission assessment include nutritional, skin, dental, neurological, activities of daily living, toileting, cognitive status, mental status, and potential for discharge and potential for rehabilitation assessments.

Employee #23 confirmed during an interview conducted on 01/07/2022, that the patient medical records were missing several components of the admission assessment and they were incomplete.

Based on record review and staff interview, it was determined the facility failed to ensure within their Emergency Preparedness plan that they incorporated documentation to include the needs of the patient population they serve or a delegation of authority as part of the continuity of operations. Failure to develop a continuity plan involving the patient population which includes delegation of authority and succession plans may cause disruption of services to patients/clients during an emergency which could lead to harm.

Findings include:

Observation during review on January 5-6, 2022 revealed that the facility was unable to locate any documentation addressing the needs of the patient population within the current written plan. Additionally, the facility did not have a succession plan that would be used for an emergency operation that also included the required delegation of authority.

Employees #2, #5, and #6 confirmed during the exit conference that the facility was unable to locate any documentation addressing the needs of the patient population or a succession plan with the delegation of authority within the current written plan.

Based on the review of the Emergency Plan (EP), facility record review, and interview, it was determined the facility failed to develop and implement emergency preparedness policies and procedures to describe its role in providing care at alternate care sites during an emergency. Failure to develop emergency policy and procedure at alternative care sites may cause harm to the residents during an emergency.

§485.625(b)(8).
[(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. At a minimum, the policies and procedures must address the following:]
(8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

Findings include:

During document review on January 5-6, 2022 it was revealed the facility's Emergency Plan related to the section which addresses policies and procedures did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.

Employees #2, #5, and #6 confirmed during an interview that the facility EP plan did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.

Based on the review of the facility Emergency Plan (EP) record review, and staff interview, it was determined the facility failed to develop an emergency officials' contact list. Failure to have an emergency officials' contact list during an emergency could lead to harm to both patients and staff if specific Federal, State, tribal, regional, and local emergency preparedness staff or other sources of assistance are not known if the need to contact them should arise

The CAH 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. The communication plan must include all of the following:
Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.

Findings include:

Observations during document review on January 5-6, 2022 revealed the facility failed to maintain a complete list of Federal, State, tribal, regional, local emergency preparedness staff and Other sources of assistance

Staff members #2, #5 and #6 confirmed during the exit conference the facility failed to maintain a complete list of Federal, State, tribal, regional, local emergency preparedness staff and Other sources of assistance.

Based on the review of the facility's 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, interviews, and record reviews conducted on January 5-6, 2022, revealed that the facility failed to provide documentation that new and existing staff reviewed the emergency preparedness policies and procedures. The facility stated the training was ongoing and staff appeared to have EP knowledge but no documentation was provided.

Employees #2, #5 and #6 confirmed during the exit interview the facility failed to provide documentation that new and existing staff reviewed the emergency preparedness policies and procedures.

Based on the review of the facility's Emergency Preparedness Testing Requirements, record review, and staff interviews, 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 January 5-6, 2022 it was revealed the facility was missing documents proving participation in a full-scale exercise (FSE) that was community-based. The facility was also missing documents proving a facility-based exercise or tabletop drill for two cycles.

Employees #2, #5, and #6 confirmed 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 three years.