HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2012 edition.

Failure to ensure a fire-safe environment of hospital hazards risks patient, visitor, and staff safety.

Findings included:

Refer to deficiencies written on Life Safety Code Inspection Report found at shell 94SB21.
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Based on observation, interview, and document review, the Critical Access Hospital failed to meet the requirements for the Condition of Participation for Provision of Services.

Failure to establish and implement policies and procedures for hospital services provided to all patients admitted to the hospital risks substandard and inconsistent care which can lead to negative patient outcomes.

Findings included:

1. Failure to develop and implement policies and procedures to define standards of care for Emergency Services, Labor and Delivery/Family Birth Center, Medical Surgical or Surgical Services.

Cross Reference: C 1006

2. Failure to ensure staff completed and documented neonatal vital sign assessments.

3. Failure to ensure staff completed and documented vital signs.

4. Failure to ensure an effective process for safe administration of pain medications to include a pain management policy.

Cross Reference: C 1046

5. Failure to ensure staff completed and documented initial admission assessment.

Cross Reference: C 1048

6. Failure to ensure effective processes for medication administration to include written orders for self-administered medications.

7. Failure to ensure staff complete and document pain assessment and reassessment.

8. Failure to ensure staff complete and document neonatal pain assessment and reassessment.

Cross Reference: C 1049

Due to the cumulative effect of these findings, the Condition of Participation at 42 CFR 485.635 Provision of Services was NOT MET.
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Based on record interview and interview, the Critical Access Hospital failed to develop and implement policies and procedures to define standards of care for Emergency Services, Labor and Delivery/Family Birth Center, Medical Surgical or Surgical Services.

Failure to implement policies and procedures risks inappropriate and/or ineffective patient care and poor patient outcomes.

Findings included:

1. On 02/07/23 at 9:25 AM, Surveyor #9 and Emergency Department Manager (Staff #903) and Emergency Department Director (Staff #904) toured the Emergency Department. Surveyor #9 interviewed Staff #904 regarding standards of care for the Emergency Department such as pain assessment and reassessment, discharge criteria, vital sign frequency and nursing assessments. Staff #904 stated that there is not a policy which defines the standards of care in the Emergency Department.

2. On 02/07/23 at 1:35 PM, Surveyor #9 and Medical Surgical/Family Birth Center Director (Staff #906) toured the Medical Surgical area. Surveyor #9 interviewed Staff #906 regarding standards of care for the Medical Surgical area. Staff #906 stated that there is not a policy which defines standards of care for the Medical Surgical area.

3. On 02/07/23 at 3:35 PM, Surveyor #9 and Medical Surgical/ Family Birth Center Director (Staff #906) toured the Labor and Delivery/Family Birth Center area. Surveyor #9 interviewed Staff #906 regarding standards of care for the Labor and Delivery/Family Birth Center area. Staff #906 stated that there is not a policy which defines standards of care for the Labor and Delivery/Family Birth Center area.

4. On 02/08/23 at 8:15 AM, Surveyor #9 and Surgical Services Director (Staff #907) toured the Surgical Services area. Surveyor #9 interviewed Staff #907 regarding standards of care for the Surgical Services area. Staff #907 stated that they would provide the document. No standard of care for Surgical Services was provided by the end of the survey.

5. On 02/08/23 at 12:45 PM, Surveyor #9 interviewed Chief Nursing Officer (Staff #905) regarding policies which define standards of care for each department. Staff #905 verified that there is no standard of care policy for the Emergency Department, Labor and Delivery/Family Birth Center, Medical Surgical or Surgical Services.
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Item #1 - Neonatal vital sign assessment

Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure staff completed and documented vital sign assessments for 3 of 3 neonatal patients reviewed (Patient #205, #207, and #208).

Failure to perform vital sign assessments of the neonate creates a risk that patients would not receive medical treatment appropriate to their care needs.

Findings included:

1. Document review of the hospital policy and procedure titled, "Nursery Standards of Care Procedure," Policy Stat ID number 10682943, last approved 11/21, showed that the neonate vital signs following birth are to be documented every 15 minutes X 4, then every 30 minutes X 2, then every 4 hours if stable.

2. On 02/08/23, between 9:50 AM and 12:30 PM, Surveyor #2 and Family Birth Unit RN (Staff #207), reviewed the medical charts. The review showed the following:

a. Patient #205 was born on 01/15/23 at 8:56 PM. The initial vital signs were documented at 11:00 PM.

b. Patient #207 was born 01/26/23 at 8:18 AM. Vital signs were documented at 8:00 PM with the next vital sign documented on 01/27/23 at 8:34 AM (a period of approximately 12 hours), again with the next vital sign documented at 2:42 PM (a period of approximately 6 hours).

c. Patient #208 was born on 12/30/22 at 8:27 AM. Vital signs were documented on 12/30/22 at 8:30 AM and 9:00 AM (missed 15 minutes). Vital signs were documented at 10:00 AM (missed a period of 30 minutes). Vital signs were documented at 1:00 PM and again at 7:00 PM (missing a period of approximately 6 hours).

3. At the time of the review, Staff #207 verified the missing vital sign documentation.

Item #2 - Post-partum vital sign assessment

Based on interview, document review, and review of hospital policies and procedures, the hospital failed to ensure staff completed and documented vital sign for 2 of 3 post-partum reviewed (Patient #206 and #210).

Failure to perform vital sign assessments of the post-partum creates a risk that patients would not receive medical treatment appropriate to their care needs.

Findings included:

4. Document review of the hospital policy and procedure titled, "Standards of Care Post-Partum Procedure", Policy Stat ID number 12808935, last approved 12/22, showed that post-partum patient vital signs are to be documented upon admission to the unit and every 4 hours during their stay.

5. On 02/08/23, between 9:50 AM and 12:30 PM, Surveyor #2 and Family Birth Unit RN (Staff #207), reviewed the medical charts. The review showed:

a. Patient #206 was admitted on 01/26/23. Patient #206 had vital signs documented on 01/26/23 at 2:42 PM and on 01/26/23 at 8:00 PM (a period of approximately 5 hours). The next vital signs were documented on 01/27/23 at 3:51 AM (a period of approximately 7 hours).

b. Patient #210 was admitted on 12/30/22. After delivery, Patient #210 was admitted on 12/30/23 to the post-partum unit at 10:14 AM. Patient #210 had vital signs documented on 12/30/22 at 9:45 PM and on 12/31/22 at 3:09 AM (a period of approximately 5 hours). The next vital sign assessment was documented at 8:00 AM (a period of approximately 5 hours).

6. At the time of the review, Staff #207 verified vital sign documentation and stated unit policy was vital signs every 4 hours.

Item #3 Pain management

Based on observation, interview, and review of medical records, the Critical Access Hospital failed to have an effective process for safe administration of pain medications to include a pain management policy for 2 of 2 surgical patients reviewed (Patient #902 and #903).

Failure to develop and implement a pain management policy and procedure places patients at risk for unintended dosing of medication, inadequate pain control, as well as potential adverse drug reactions.

Findings included:

1. Document review of the hospitals policy and procedure titled, "Provider Order and Medication Verification Policy, "PolicyStat ID #11226481, last approved 02/16/22, showed that orders that are unclear must be clarified prior to implementation.

Document review of the hospital's policy and procedure titled, "Medication Administration," PolicyStat ID #11882205, last approved 06/10/22, showed that the following:

a. The hospital will follow ten rights for safe medication administration to include right time, right assessment, and right evaluation.

b. If a patient is tolerating oral fluids, oral medication administration is selected.

2. On 02/08/23 at 4:00 PM, Surveyor #9 and Performance Improvement Specialist (Staff #901) reviewed the medical record of Patient #902 who was admitted to the hospital on 01/30/23 for a small bowel obstruction. On 01/30/23 at 2:29 PM, the provider placed an order in the medical record for Morphine Sulfate (an opioid pain medication) 1-4 milligrams intravenously every 1 hour as needed for pain. On 01/30/23 at 2:34 PM, the same provider placed a second order in the medical record for Oxycodone (an opioid pain medication) 5-10 milligrams orally every 6 hours as needed for pain. There were no other administration instructions included in the order.

3. A review of the patient's medication administration record for 01/31/22 showed the following:

a. On 01/31/22 at 1:22 AM, the patient received Morphine Sulfate 2 milligrams intravenously for a pain score of 7.

b. On 01/31/22 at 4:24 AM, the patient received Oxycodone 10 milligrams orally for a pain score of 8.

c. On 01/31/22 at 12:07 PM, the patient received Oxycodone 10 milligrams orally for a pain score of 7.

d. On 01/31/22 at 11:03 PM, the patient received Oxycodone 10 milligrams orally and Morphine Sulfate 1 milligram for a pain score of 8.

4. On 02/09/23 at 9:10 AM, Surveyor #9 and Performance Improvement Specialist (Staff #901) reviewed the medical record of Patient #903 who was admitted to the hospital on 01/17/23 for a knee replacement. On 01/17/23 at 1:12 PM, the provider placed an order in the medical record for Hydromorphone (an opioid pain medication) 1-2 milligrams intravenously every 2 hours as needed for pain. On 01/17/23 at 1:12 PM, the same provider placed a second order in the medical record for Hydrocodone/Acetaminophen (an opioid pain medication) 5-325 milligrams 1-2 tablets orally every 4-6 hours as needed for pain. There were no other administration instructions included in the order.

5. A review of the patient's medication administration record for 01/18/22 showed the following:

a. On 01/18/23 at 2:12 AM, the patient received Hydrocodone/Acetaminophen 5/325 milligrams 2 tablets orally for a pain score of 8.

b. On 01/18/23 at 5:59 AM, the patient received Hydromorphone 1 milligram intravenously for a pain score of 10.

c. On 01/18/23 at 7:43 AM, the patient received Hydrocodone/Acetaminophen 5/325 milligrams 2 tablets orally for a pain score of 7.

d. On 01/18/23 at 8:01 AM, the patient received Hydromorphone 1 milligram intravenously for a pain score of 10.

e. On 01/18/23 at 10:13 AM, the patient received Hydromorphone 2 milligrams intravenously for a pain score of 10.

f. On 01/18/23 at 12:00 PM, the patient received Hydromorphone 1 milligram intravenously for a pain score of 8.

g. On 01/18/23 at 1:54 PM, the patient received Hydrocodone/Acetaminophen 5/325 milligrams 1 tablet orally for a pain score of 9.

h. On 01/18/23 at 3:21 PM, the patient received Hydromorphone 1 milligram intravenously for a pain score of 8.

i. On 01/18/23 at 4:58 PM, the patient received Hydrocodone/Acetaminophen 5/325 milligrams 1 tablet orally for a pain score of 9.

j. On 01/18/23 at 5:20 PM, the patient received Hydromorphone 1 milligram intravenously for a pain score of 8.

k. On 01/18/23 at 7:29 PM, the patient received Hydromorphone 1 milligram intravenously for a pain score of 8.

l. On 01/18/23 at 8:46 PM, the patient received Hydrocodone/Acetaminophen 5/325 milligrams 2 tablets orally for a pain score of 7.

m. On 01/18/23 at 9:48 PM, the patient received Hydromorphone 1 milligram intravenously for a pain score of 8.

n. On 01/18/23 at 11:54 PM, the patient received Hydromorphone 1 milligram intravenously for a pain score of 8.

6. After the review, Surveyor #9 interviewed Registered Nurse (Staff #910) on the medical surgical floor about the process of pain medication administration when there are multiple pain medication orders and/or ranges. Staff #910 stated that the nursing staff will decide based on their assessment what medication and/or dose to administer to the patient.
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Based on interview, record review, and review of policy and procedure, the hospital failed to ensure staff documented an initial admission assessment for 1 of 3 patients reviewed (Patient #204).

Failure to perform an initial admission assessment of the patient creates risk that patients would not receive medical treatment appropriate to their care needs.

Findings included:

1. On 02/08/23 between 9:50 AM and 12:30 PM, Surveyor #2 and Family Birth Unit Staff RN (Staff #207) reviewed the medical charts of 3 Patient #204. Patient #204 was admitted to the Family Birth Unit on 01/15/23 at 10:03 AM. Surveyor #2 was unable to find evidence of the initial admission assessment in the electronic medical record.

2. At the time of the review, Staff #207 verified the missing initial assessment documentation and stated all patients should have an initial assessment when admitted to the unit.
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Item #1 Self Administered Medications

Based on observation, interview, and document review the Critical Access Hospital failed to ensure effective processes for medication administration including written orders for self administered medication 1 of 3 obstetrical patients reviewed (Patient #901).

Failure to develop and implement such policies and procedures places all patients in the hospital at risk for unsafe care, harm, and death.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Self-Administration of Medications," PolicyStat ID 12923716, last approved 01/04/23, showed the following:

a. Self-administration of drugs by patients is allowed only with a written order by the attending physician.

b. The following medications may be self-administered:

i. nasal sprays

ii. ophthalmic drops

iii. topical preparations

iv. antacids

v. birth control pills

vi. inhalers

vii. insulin for teaching purposes only

2. On 02/07/23 at 3:35 PM, Surveyor #9 interviewed Family Birth Center RN (Staff #909) regarding routine medication administration practices after delivery. Staff #909 stated that each patient has an order for a self-administered medication pack that is obtained from the Pyxis (the automated dispensing cabinet) which contains Tylenol (a non-narcotic pain reliever), Ibuprofen (a non-narcotic pain reliever), and Colace (a stool softener). The patient is given a Self-Administration of Medications record to write the medications that they take, pain scale, time, and dosage. That paper is scanned into the medical record.

3. On 02/10/23 at 9:00 AM, Surveyor #9 and Performance Improvement Specialist (Staff #901) and Director of Pharmacy (Staff #908) reviewed the medication orders for Patient #901. Surveyor #9 could find no evidence of an order for the self-administered medication pack. Surveyor #9 could find no evidence of a Self-Administration of Medications paper record. Documentation in the record showed that the patient has pain that was controlled with Tylenol and Ibuprofen.

4. On 02/10/23 at 9:10 AM, Staff #908 verified that a self-administered medication pack was removed on override from the Pyxis for Patient #901 and there was no order entered into the computer by a provider for those medications. Staff #901 verified the missing documentation of a Self-Administration of Medication record.

Item #2 Pain assessment and reassessment

Based on interview, record review, and review of policy and procedure, the hospital failed to ensure staff members completed and documented pain assessments and/or reassessments for 6 of 9 patients reviewed in the Emergency Department, Family Birth Unit, and Medical Surgical Unit (Patient # 201, Patient # 202, Patient #203, Patient #204, Patient #206, and Patient #209).

Failure to assess and reassess a patient's pain risks inconsistent, inadequate, or delayed relief of pain and risks patient harm related to delayed recognition of adverse effects of pain medication.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Medication Administration Policy & Procedure," Policy Stat ID number 11882205, last approved 06/22, showed all medications requiring a follow-up assessment evaluation will be documented by the staff, including pain medication and IV fluids.

2. On 02/07/23 between 8:30 AM and 11:40 AM, Surveyor #2 and the Director of Emergency and Cardiopulmonary Department (Staff #203), and Emergency Department Manager (Staff #204) reviewed the medical charts. The review showed the following:

a. Patient #201 was seen in the Emergency Department on 02/06/23 with a chief complaint of left-sided chest and nasal pain. On 02/06/23 at 10:47 PM, the patient received acetaminophen (a medication used to treat pain) 975 milligrams orally for pain rated at 6/10. Surveyor #2 could not find evidence of a documented pain reassessment after pain medication administration.

b. Patient #202 was a 5-year-old seen in the Emergency Department on 02/06/23 with a chief complaint of bilateral ear pain. Surveyor #2 could not find any evidence of a pain assessment during this visit.

c. Patient #203 was a 7-year-old seen in the Emergency Department on 02/04/23 for left arm pain after a fall. On 02/04/23 at 8:21 PM, the patient received Morphine (a medication used to treat pain) 1 milligram intravenously for a pain score of 6/10. Surveyor #2 could not find any evidence of a pain reassessment before discharge at 10:04 PM.

3. At the time of the review, Staff #204 verified the missing pain assessment and reassessments. Surveyor #2 requested an Emergency Department-specific pain assessment policy. Staff #204 stated there is not a policy related to pain assessment and reassessment for the Emergency Department.

4. On 02/08/23 between 9:50 AM and 12:30 PM, Surveyor #2 and Family Birth Unit Staff RN (Staff #207) reviewed the medical charts. The review showed the following:

a. Patient #204 delivered a baby vaginally on 01/15/23. On 01/16/23 at 6:01 AM the patient received Toradol (a medication used to treat pain) 30 milligrams intravenously. Surveyor #2 could not find any evidence of a pain assessment before pain medication administration.

b. Patient #206 had a scheduled cesarean section on 01/26/23. On 01/28/23 at 3:03 AM the patient received Vicodin (a medication used to treat pain) 5/325 milligrams one tablet orally. Surveyor #2 could not find any evidence of a pain assessment before pain medication administration or a pain reassessment following administration.

5. At the time of the review, Staff #207 verified the missing pain assessment and reassessments.

6. On 02/09/23 between 9:05 AM and 10:39 AM, Surveyor #2 and Family Birth Unit Staff RN (Staff #207) reviewed the medical charts. Patient #209 was admitted on 01/30/23 for an exploratory laparotomy surgical procedure for a small bowel obstruction. After surgery, the provider placed an order in the medical record for Morphine (a medication used to treat pain) 4-6 milligrams intravenously every 6 hours as needed for pain. The review showed the following:

a. On 01/31/23 at 12:25 PM, Patient #209 received Morphine 4 milligrams intravenously for a pain score of 6/10. Surveyor #2 could not find any evidence of a pain reassessment after pain medication administration.

b. On 02/01/23 at 6:13 AM, Patient #209 received Morphine 4 milligrams intravenously for a pain score of "reports pain". Surveyor #2 could not find any evidence of a pain reassessment after pain medication administration.

7. At the time of the review, Staff #207 verified the missing pain assessment and pain reassessments.

Item #3 Neonatal pain assessment

Based on interview and record review, the hospital failed to ensure staff members completed and documented pain assessments for 3 of 3 neonatal patients (Patient # 205, Patient # 207, and Patient #208).

Failure to assess and reassess a patient's pain risks inconsistent, inadequate, or delayed relief of pain and risks patient harm related to delayed recognition of adverse effects of pain medication.

Findings included:

8. On 02/08/23 between 9:50 AM and 12:30 PM, Surveyor #2 and Family Birth Unit Staff RN (Staff #207) reviewed the medical charts. The review showed the following:

a. Patient #205 was a baby born vaginally on 01/15/23. Surveyor #2 could not find any evidence of a pain assessment during the neonate's stay.

b. Patient #207 was a baby born by cesarean section on 01/26/23. Surveyor #2 could not find any evidence of pain assessment during the neonate's stay.

c. Patient #208 was a baby born by cesarean section on 12/30/22. Surveyor #2 could not find any evidence of pain assessment during the neonate's stay.

9. At the time of the review, Staff #207 verified there were no pain assessments completed on the neonates. Staff #207 was interviewed regarding the standard of care for assessing neonatal pain. Staff #207 stated, "personally I assess pain, but there is no place to document the assessment in the medical record".
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Based on interview and document review, the Critical Access Hospital failed to fully develop and implement their water management plan designed to reduce the risk of Legionella and other water-borne diseases in the patient population.

Failure to develop and implement a hospital-wide water management plan puts patients, staff and visitors at risk of infection from water-borne pathogens.

Reference: Centers for Medicare and Medicaid Services (CMS) Survey & Certification Letter S&C 17-30 (6/2/2017): Subject line: "Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD)"- Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. The plan must meet the following criteria:

a. Conduct a risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system.

b. Implement a water management program that considers the ASHRAE industry standard and/or the CDC toolkit, to include control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and/or environmental testing for pathogens.

c. Specify testing protocols and acceptable ranges for control measures and document the results of testing and provide corrective actions taken when control limits are outside of acceptable ranges.

Findings included:

1. Document review of the hospital's policy titled, "Water Management Procedure," PolicyStat ID 12913756, last approved 01/23, showed that the facility will hire a third-party vendor to develop a comprehensive water management plan.

Document review of the binder labeled, "Nalco Water, an Ecolab Company, Water Management Program for Building Water Systems, Prepared for Whitman County Hospital," copyrighted 2018, showed a previously developed water management plan for the hospital that did not include all the current requirements listed above.

2. On 02/09/23 at 9:00 AM, Surveyor #4 interviewed the Director of Support Services (Staff #401) about the Water Management Plan. Staff # 401 confirmed the previously developed plan needed to be updated to include a current risk assessment, relevant testing parameters and mitigation steps.

Staff #401 stated the plan would be updated, reviewed for approval, and implemented as soon as possible.
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Based on document review and interview, the Critical Access Hospital failed to develop measurable action plans and failed to monitor activities following analysis of adverse events for 2 of 2 patient cases reviewed.

Failure to develop action plans aimed at improving patient outcomes and implement monitoring for those plans risks patient safety.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Adverse Event Procedure," PolicyStat ID 1242183, approved 09/22, showed the following:

a. An action plan will be implemented for each adverse event consistent with the findings of the root cause analysis.

b. The action plan will include the following:

i. How each finding will be addressed and corrected.

ii. When each correction will be completed.

iii. Who is responsible to make the corrections.

iv. What action will be taken to prevent the adverse event from recurring.

v. A monitoring plan to assess the effectiveness of the corrective action plan including who is responsible for monitoring the schedule.

1. On 02/09/23 at 1:30 PM, Surveyor #9 and Performance Improvement Specialist (Staff #901) and Director of Quality (Staff #902) reviewed the hospital's Quality Improvement processes related to Adverse Events and Root Cause Analysis. During the review, two Root Cause Analysis were reviewed. Surveyor #9 found no evidence that a measurable corrective action plan with measurable outcomes was developed, or follow-up monitoring performed for 2 of 2 of the RCA's reviewed.

2. At the time of the review, Staff #901 verified that the documents did not contain measurable outcomes and was unable to answer if the action plan had been completed.
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Based on interview and review of the hospital's quality program and quality documents, the Critical Access Hospital failed to implement, monitor, and evaluate performance improvement action plans as directed by its quality plan for quality indicators consistently not meeting hospital defined targets.

Failure to implement corrective action plans for identified problems and monitor for sustained improvement limits the hospital's ability to provide high quality clinical care and improve patient outcomes.

Findings included:

1. Document review of the hospital's policy titled, "Organizational Quality Plan," PolicyStat ID 12451432, last approved 10/03/22, showed the following:

a. Goals for the program are to identify and monitor key quality and safety performance indicators.

b. Projects may be system wide and comprehensive, or department and population focused. All require the following:

i. Identification of measurable structural, process or outcome indicators.

ii. Collection of data for ongoing measurement.

iii. Evaluation of performance against predetermined thresholds.

iv. Timely evaluation of effectiveness of action.

v. Reliance on the scientific method.

c. The Whitman Hospital and Medical Clinic Model for Process improvement and analysis of data and information is Plan, Do, Study, Act (PDSA).

2. On 02/10/23 from 9:15 AM until 10:15 AM, Surveyor #9 and Performance Improvement Specialist (Staff #901) and Director of Quality (Staff #902) reviewed the hospital's quality improvement program. Surveyor #9 reviewed the data reflected on the hospital's' dashboards.

a. There was data collection from 03/31/19 to 09/30/22 related to the cesarean section rate which did not meet hospital target for several months.

b. There was data collection related to Emergency Department throughput which did not meet hospital target for several months.

c. There was data collection for a Sepsis project from January to September 2022. A project was implemented in August with an 80% target for compliance. The last data was 25% compliance with no data collected since October 2022.

3. Surveyor #9 found no evidence in review of Quality minutes that the hospital developed or implemented process improvement to address data or process improvement not meeting hospital defined targets.

3. At the time of the review, Surveyor #9 interviewed Staff #901 regarding these dashboards and projects. Staff #901 stated that they were watching the cesarean rate, decided to do nothing regarding Emergency Department throughput as this was a provider issue, and did not have staff at present to continue with the sepsis project.
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Based on document review and interview, the Critical Access Hospital (CAH) failed to establish and maintain a comprehensive emergency preparedness program.

Failure to establish and maintain a comprehensive emergency preparedness program places patients, staff, and visitors at risk for delayed or compromised care, injury, or death in the event of an emergency.

Findings included:

1. Failure to develop an emergency preparedness plan that includes all required elements.

Cross Reference: Tag E-0004

2. Failure to develop an emergency preparedness plan based on a risk assessment using a current all-hazards approach and developing strategies to address areas identified in the risk assessment.

Cross Reference: Tag E-0006

3. Failure to develop a plan that addresses the patient population including types of services offered, continuity of operations, and delegation plans.

Cross Reference: Tag E-0007

4. Failure to develop policies and procedures based on a risk assessment.

Cross Reference: Tag E-0013

5. Failure to fully develop policies and procedures for subsistence needs for staff and patients.

Cross Reference: Tag E-0015

6. Failure to develop policies and procedures for tracking staff and patients.

Cross Reference: Tag E-0018

7. Failure to develop policies and procedures for evacuation.

Cross Reference: Tag E-0020

8. Failure to develop a policy and procedure addressing a means to shelter in place during an emergency.

Cross Reference: Tag E-0022

9. Failure to develop a policy and procedure for medical documents.

Cross Reference: Tag E-0023

10. Failure to develop a policy and procedure on using volunteers or other staffing strategies in an emergency.

Cross Reference: Tag E-0024

11. Failure to develop a policy for using alternate care sites during a 1135 waiver.

Cross Reference: Tag E-0026

12. Failure to develop an updated communications plan with required names and contacts.

Cross Reference: Tag E-0030

13. Failure to document emergency official's contact information.

Cross Reference: Tag-E0031

14. Failure to document methods for sharing information.

Cross Reference: Tag E-0033

15. Failure to develop a training and testing program based on a risk assessment.

Cross Reference: Tag E-0036

16. Failure to develop a process for testing the emergency plan and conducting testing according to require intervals.

Cross Reference: Tag E-0039

Due to the scope of these findings, the Condition of Participation 42 CFR 485.625: Emergency Preparedness was NOT MET.
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Based on document review and interview, the Critical Access Hospital (CAH) failed to develop and maintain an emergency preparedness plan that contained all the required elements and was based on a current all-hazards risk assessment specific to the facility.

Failure to develop and maintain an emergency preparedness program with all of the required elements places patients, staff, and visitors at risk for delayed or compromised care, injury, or death in the event of an emergency.

Findings included:

1. Record review of the emergency preparedness plan and policies, reviewed 02/08/23, showed that the plan did not contain all of the required elements. The plan was missing the following elements:

a. The plan was not based on a current all-hazards risk assessment, the provided risk assessment was completed in 2020.

b. The policies and procedures were not developed based on identified risks from a current all-hazards risk assessment.

c. The plan did not address the specific patient population including types of services provided, continuity of operations, or delegation of authority.

d. The plan did not include a process for cooperation with other agencies.

e. The plan did not contain a policy or procedure for providing alternate care sites during an 1135 waiver.

f. The plan did not address required training and testing.

2. On 02/09/23 at 10:00 AM, Surveyor #4 interviewed the Director of Support Services (Staff #401) about the elements of the emergency preparedness program. Staff #401 stated that the CAH did not have a recent all-hazards risk assessment or the additional required policies. Staff #401 stated that he had recently taken over the position and was tasked with updating the plan 8 weeks ago. Staff #401 stated that he would refer to CMS State Operations Manual, Appendix Z for Updated Guidance for Emergency Preparedness to develop the missing elements of the CAH's emergency preparedness program.
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Based on document review and interview, the CAH failed to develop an emergency preparedness plan based on a current documented facility or community-based risk assessment utilizing an all-hazards approach and include strategies for addressing emergencies identified in that assessment.

Failure to develop an emergency preparedness plan based on a risk assessment using an all-hazards approach and failure to include strategies addressing emergencies identified in that risk assessment places patients, staff, and visitors at risk of injury or death during an emergency due to inadequate preparation.

Findings included:

1. Record review of the CAH's emergency preparedness program and policies, reviewed 02/09/23, showed that a hazard vulnerability analysis was to be completed annually.

2. On 02/09/23 at 10:00 AM, Surveyor #4 interviewed the Director of Support Services (Staff #401) about the elements of the emergency preparedness program. Staff #401 stated that the CAH did not have a recent all-hazards risk assessment. Staff #401 confirmed the last assessment was completed in 2020.
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Based on document review and interview, the CAH failed to implement emergency preparedness policies and procedures based on a current community or facility risk assessment that addresses the patient/client population.

Failure to develop policies and procedures for the CAH's specific population risks implementation of processes that are inadequate for the risks at the facility.

Findings included:


1. Record review of the CAH's emergency preparedness program and policies, reviewed 02/09/23, showed there were no specific procedures or policies to address the specific patient population.

2. On 02/09/23 at 10:00 AM, Surveyor #4 interviewed the Director of Support Services (Staff #401) about the elements of the emergency preparedness program. Staff #401 confirmed the current policy did not address any specific patient populations.
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Based on document review and interview, the CAH failed to implement emergency preparedness policies and procedures based on a current community or facility risk assessment that included a communications plan that is updated at least every 2 years.

Failure to develop policies and procedures for the CAH's specific communication needs risks implementation of processes that are inadequate for the facility.

Findings included:

1. Record review of the CAH's emergency preparedness program and policies, reviewed 02/09/23, showed there was not an updated communications plan.

2. On 02/09/23 at 10:00 AM, Surveyor #4 interviewed the Director of Support Services (Staff #401) about the elements of the emergency preparedness program. Staff #401 confirmed the current communications plan had not been updated within the past 2 years.
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Based on document review and interview, the CAH failed to implement emergency preparedness policies and procedures based on a current community or facility risk assessment that fully addresses subsistence needs for staff and patients who evacuate or shelter in place.

Failure to fully develop policies and procedures for the subsistence needs of the CAH's staff and patients risks unsafe conditions during an emergency.

Findings included:

1. Record review of the CAH's emergency preparedness program and policies, reviewed 02/09/23, showed there are procedures outlined for the provisions of food, water, sanitary supplies and fuel, but the policy did not include provisions for pharmaceutical supplies.

2. On 02/09/23 at 10:00 AM, Surveyor #4 interviewed the Director of Support Services (Staff #401) about the elements of the emergency preparedness program. Staff #401 confirmed the current policy did not address pharmaceutical supplies.
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Based on document review and interview, the CAH failed to implement emergency preparedness policies and procedures based on a current community or facility risk assessment that includes a process to track staff and patients.

Failure to develop policies and procedures to track the CAH's staff and patients risks unsafe conditions during an emergency.

Findings included:

1. Record review of the CAH's emergency preparedness program and policies, reviewed 02/09/23, showed there were no procedures outlined for tracking on-duty staff or sheltered patients during an emergency.

2. On 02/09/23 at 10:00 AM, Surveyor #4 interviewed the Director of Support Services (Staff #401) about the elements of the emergency preparedness program. Staff #401 confirmed the current policy did not include a system for tracking staff or patients.
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Based on document review and interview, the CAH failed to implement emergency preparedness policies and procedures based on a current community or facility risk assessment that includes a process for evacuation.

Failure to develop policies and procedures to evacuate the CAH's staff and patients risks unsafe conditions during an emergency.

Findings included:

1. Record review of the CAH's emergency preparedness program and policies, reviewed 02/09/23, showed there were no procedures for the safe evacuation that included the care and treatment needs of evacuees, staff responsibilities, transportation, identification of evacuation locations, and primary and alternate means of communication with external sources of assistance during an emergency.

2. On 02/09/23 at 10:00 AM, Surveyor #4 interviewed the Director of Support Services (Staff #401) about the elements of the emergency preparedness program. Staff #401 confirmed the current policy did not include the required evacuation elements.
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Based on document review and interview, the CAH failed to implement emergency preparedness policies and procedures based on a current community or facility risk assessment that includes procedures for sheltering in place.

Failure to develop policies and procedures to shelter in place at the CAH risks unsafe conditions during an emergency.

Findings included:

1. Record review of the CAH's emergency preparedness program and policies, reviewed 02/09/23, showed there were no procedures outlined for patients, staff and volunteers who shelter in place at the CAH during an emergency.

2. On 02/09/23 at 10:00 AM, Surveyor #4 interviewed the Director of Support Services (Staff #401) about the elements of the emergency preparedness program. Staff #401 confirmed the current policy did not include the required shelter in place elements.
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Based on document review and interview, the CAH failed to implement emergency preparedness policies and procedures based on a current community or facility risk assessment that includes a system of medical documentation that preserves patient information, protects confidentiality, and secures and maintains availability of records.

Failure to develop policies and procedures to maintain safe access to patient records risks unsafe conditions during an emergency.

Findings included:

1. Record review of the CAH's emergency preparedness program and policies, reviewed 02/09/23, showed there were no procedures outlined for access to patient medical information and records during an emergency.

2. On 02/09/23 at 10:00 AM, Surveyor #4 interviewed the Director of Support Services (Staff #401) about the elements of the emergency preparedness program. Staff #401 confirmed the current policy did not include a process for continued safe access to medical records.
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Based on document review and interview, the CAH failed to implement emergency preparedness policies and procedures based on a current community or facility risk assessment that includes procedures for the use of volunteers during an emergency.

Failure to develop policies and procedures for the use of volunteers or other staffing strategies risks unsafe conditions during an emergency.

Findings included:

1. Record review of the CAH's emergency preparedness program and policies, reviewed 02/09/23, showed there were no procedures outlined for the use of volunteers or other staffing strategies, including the process and role for integration of state and federally designated health care professionals to address surge needs during an emergency.

2. On 02/09/23 at 10:00 AM, Surveyor #4 interviewed the Director of Support Services (Staff #401) about the elements of the emergency preparedness program. Staff #401 confirmed the current policy did not include a process for the use of volunteers. Staff #401 stated that the CAH would determine if they will use volunteers during an emergency and update the plan accordingly.
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Based on document review and interview, the Critical Access Hospital (CAH) failed to develop a policy for the CAH's role during an 1135 waiver for providing care at an alternate care site.

Failure to develop a policy for providing care at an alternate care site during an 1135 waiver risks the inability of the CAH to provide adequate care should they need to relocate patients during the activation of the emergency preparedness plan.

Findings included:

1. Record review of the CAH's emergency preparedness program and policies, reviewed 02/09/23, showed that no policy specifying the CAH's role for providing care at alternate care sites under an 1135 waiver was present.

2. On 02/09/23 at 10:00 AM, Surveyor #4 interviewed the Director of Support Services (Staff #401) about the elements of the emergency preparedness program. Staff #401 confirmed the current plan did not include a policy for providing care at alternate care sites under an 1135 waiver.
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Based on document review and interview, the Critical Access Hospital (CAH) failed to update its communication policy that includes the names and contact information for staff, entities providing services under arrangement, patients' physicians, other CAHs and volunteers.

Failure to maintain a current policy for the contacts within the communication plan risks inadequate care continuity if communications become disrupted during an emergency.

Findings included:

1. Record review of the CAH's emergency preparedness program and policies, reviewed 02/09/23, showed that the communications plan was not updated within the past 3 years.

2. On 02/09/23 at 10:00 AM, Surveyor #4 interviewed the Director of Support Services (Staff #401) about the elements of the emergency preparedness program. Staff #401 confirmed the current communications plan was not updated since 2020.
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Based on document review and interview, the Critical Access Hospital (CAH) failed to develop an updated communications policy that includes federal, state, tribal, regional, and local emergency preparedness staff as well as other sources of assistance.

Failure to maintain a current policy for the contacts within the communication plan risks inadequate care continuity if communications become disrupted during an emergency.

Findings included:

1. Record review of the CAH's emergency preparedness program and policies, reviewed 02/09/23, showed that the communications plan did not contain the required contact elements.

2. On 02/09/23 at 10:00 AM, Surveyor #4 interviewed the Director of Support Services (Staff #401) about the elements of the emergency preparedness program. Staff #401 confirmed the current plan did not include the updated contacts as required.
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Based on document review and interview, the CAH failed to implement emergency preparedness policies and procedures based on a current community or facility risk assessment that includes a method for sharing information and medical documentation for patients under the CAH's care, as necessary, with other providers.

Failure to develop policies and procedures that include methods for sharing patient's information and medical documentation risks inadequate care continuity during an emergency.

Findings included:

1. Record review of the CAH's emergency preparedness program and policies, reviewed 02/09/23, showed there were no methods for sharing documentation included.

2. On 02/09/23 at 10:00 AM, Surveyor #4 interviewed the Director of Support Services (Staff #401) about the elements of the emergency preparedness program. Staff #401 confirmed the current policy did not include a method to share patient information and medical documentation as required.
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Based on document review and interview, the CAH failed to implement updated emergency preparedness policies and procedures based on a current community or facility risk assessment that includes training and testing designed to analyze the CAH's overall emergency preparedness program.

Failure to develop and biennially update a training and testing program risks the inability for the CAH to determine if there are areas that need improvement in the program and update accordingly to ensure optimal patient care and safety during an emergency.

Findings included:

1. Record review of the CAH's emergency preparedness program and policies, reviewed 02/09/23, showed there was no updated training and testing program detailed in the plan.

2. On 02/09/23 at 10:00 AM, Surveyor #4 interviewed the Director of Support Services (Staff #401) about the elements of the emergency preparedness program. Staff #401 confirmed the CAH had not updated training and testing for the emergency program as required.
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Based on document review and interview, the CAH failed to implement emergency preparedness policies and procedures based on a current community or facility risk assessment that includes exercises (either tabletop, workshop, or live event(s)) designed to annually test the CAH's overall emergency preparedness program.

Failure to develop a testing program risks the inability for the CAH to determine if there are areas that need improvement in the program and update accordingly to ensure optimal patient care and safety during an emergency.

Findings included:

1. Record review of the CAH's emergency preparedness program and policies, reviewed 02/09/23, showed there was no testing program detailed in the plan. The plan did not provide any details on developing testing exercise or after-action plans. There was no evidence the CAH staff conducted any exercises for emergency preparedness.

2. On 02/09/23 at 10:00 AM, Surveyor #4 interviewed the Director of Support Services (Staff #401) about the elements of the emergency preparedness program. Staff #401 confirmed the CAH had not completed any emergency prep testing so far this year or in the previous year (2022).
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