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Based on observation, interview, policy review, and review of the manufacturer's instruction for use of disinfection wipes, the facility failed to ensure staff were following the instructions to ensure compliance with the infection control processes. This failure had the potential to affect the 18 patients and/or the outpatients receiving treatment in the operating rooms (ORs).

Findings include:

During an observation on 11/08/2023 at 11:02 AM, the Environmental Services (EVS) employee entered Operating Room 2 (OR2) and started to wipe down equipment. When asked about the product being used, EVS stated, "the purple top ones." Review of the container with the purple top showed it was a "PDI Sani Cloth" wipe. EVS was observed to clean the electronic equipment, intravenous (IV) poles, directional light, table, cords etc. Responding to a question regarding contact time (explained wet time, dwell time three different times) at 11:06 AM, EVS stated "It dries right away though it says two minutes. It's alcohol so it dries right away."

At 11:10 AM on 11/08/2023, Registered Nurse (RN)5 entered OR2 and started wiping down the stainless-steel table with PDI Sani Cloths. When asked about the contact time for the disinfecting wipe, RN5 stated, "May I refer to something? I error on the side of caution and it's three minutes from the time I stop wiping to before I put anything on the table." When asked if that was wet time, RN5 stated, "I just wait three minutes." RN5 was observed watching the clock and started setting up the table at 11:15 AM.

In the anteroom (room with supplies) between the two ORs was another tub of wipes. On 11/08/2023 at 11:17 AM, EVS was going to OR1 to clean and was asked about the second tub of wipes "Diversey Easy Wipe." EVS explained that was a Virex wipe that EVS pours in the solution and that those wipes were used for terminal cleaning at the end of the day. The container was not marked with any indication of what solution was on the wipes.

On 11/08/2023 at 11:54 AM, the Sterile Processing Technician (SPT) was observed wiping down the scope cleaning sinks with PDI Sani Cloths, even though water droplets remained on sides and bottom of sinks and ledges around the sinks. Then at 11:55 AM, SPT removed a plastic liner from a bin used to transport dirty endoscopes, disposing of the liner; performed a glove change, then used a PDI Sani Cloth on the interior and exterior of the bin. SPT walked a few feet further into the processing room and put the gray tray onto a cart. The tray was observed to be drying/streaking. SPT confirmed at 11:57 AM that within ten seconds of wiping the tray was showing signs of drying already.

Review of the facility printed "PDI Super Sani Cloth" instructions for use, provided by the facility Infection Preventionist (IP) showed:
" . . . 3b Unfold a clean wipe and thoroughly wet surface.
4. Allow the treated surface to remain wet for two (2) minutes. Let air dry. . .."
The IP confirmed the surface is to stay wet for two minutes.

Review of the facility policy titled "Cleaning and Disinfection of Reusable Patient Care Equipment," last revised 09/2023, showed:
"III. Policy:
A. Equipment will be clean with a hospital approved disinfectant, per manufacturer's instructions, after each patient use and on a regular schedule. . .."

Review of the facility policy titled "Environmental Cleaning," last revised 01/01/18 showed:
". . .IV. Procedure: . . .
2. Cleaning of OR/procedure room between procedures must be done with a facility-approved, EPA-registered disinfectant. . .."

Based on a review of the facility's Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), and staff interview, the Critical Access Hospital (CAH) failed to establish a Comprehensive Emergency Preparedness Program that complies with all applicable Federal Emergency Preparedness requirements that is based off the facility's all hazard risk assessment and patient population it serves. This deficient practice has the potential to put the current receiving care in the facility, any outpatients currently receiving care in the facility, and facility staff at risk in the event of an emergent event.

Findings include:

Review of page 5 of 38 of the facility's EPP indicated:
"Introduction ...a 25-bed critical access facility in Pahrump, NV providing emergency and surgical services to a rural area ...has organized, developed, and implemented an Emergency Management Program.
The plan will:
1. Prevent or lessen the impact that a disaster may have on the hospital and the community (Mitigation).
2. Identify resources essential to disaster response and recovery facilitating their access and utilization (Preparedness).
3. Prepare staff to respond effectively to disasters or emergency situations that affect the environment of care and test response mechanisms (Response).
4. Plan processes for reestablishing operations after the incident (Recovery)."
Page 6 of 38 stated:
"The Emergency Operations Plan describes a comprehensive "all hazards" response structure for coordinating the six critical areas: communications, resources and assets, safety and security, staffing, utilities and clinical activities. . .."

Review of the agency's binder labeled "Emergency Preparedness" revealed that the binder contained an EPP that was reviewed on 05/22/2023 however, the plan did not contain a Comprehensive Emergency Preparedness Plan including the Emergency Preparedness Conditions of Participation, based on the agency's all hazard risk assessment and patient population. (See findings in Tags E0004, E0006, E0007, E0013, E0015, E0018, E0020, E0022, E0023, E0024, E0030, E0032, E0033, and E0039.)

Based on interview and review of the facility's Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP documented the development of an all hazards-based facility and/or community risk assessment. This failure had the potential to affect the current patients receiving care in the facility and any outpatients that are receiving care in the facility.

Findings include:

During a review of the facility EPP on 11/08/2023 at 1:56 PM, with the Director of Plant Operations no documentation of an all hazards-based facility and/or community risk assessment was located on which the EPP policies were developed. Page 8 of 38 showed:

"Planning Activities
-Hazard Vulnerability Analysis ...Hospital identifies the potential emergencies that could affect demand for the hospital's services or its ability to provide those services, the likelihood of those events occurring, and the consequences of those events annually and when new services are added. This assessment is a Hazard Vulnerability Analysis (HVA), which is designed to assist in gaining a realist understanding of the vulnerabilities and to help focus the hospital's resources and planning efforts. All locations (main campus, offsite services, etc.) are required to have a HVA ...The community and regional HVA assessments, risk assessments and alerts also aid in the HVA assessment. A list of priority concerns is developed from the HVA and is evaluated annually. A copy of the most current HVA is attached."

There was no HVA attached.

During an interview on 11/08/2023 at 1:59 PM regarding the risk or HVA assessment, the Director of Plant Operations stated, "I don't recall it in here." No HVA was provided during the following business day afforded to the facility.

Based on interview and review of the facility's Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies were based on an all hazards-based facility and/or community risk assessment. This failure had the potential to affect the current patients receiving care in the facility and any outpatients that receiving care in the facility.

Findings include:

During a review of the facility EPP on 11/08/2023 at 1:56 PM, with the Director of Plant Operations (DPO), no documentation of an all hazards-based facility and/or community risk assessment was located on which the EPP policies were developed.

During an interview on 11/08/2023 at 2:03 PM, the Director of Plant Operations confirmed there was no hazard risk assessment in the EPP.

Based on interview and review of the facility's Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies identified the patient population that would be at risk during an emergent event. This failure had the potential to affect the current patients receiving care in the facility and any outpatients that receiving care in the facility.

Findings include:

Review of the facility's EPP on 11/08/2023 at 1:56 PM, with the Director of Plant Operations (DPO), revealed that the EPP did not address the patient population that would be at risk in the event of an emergency event.

During an interview on 11/08/2023 at 2:05 PM while reviewing the EPP, the Director of Plant Operations was asked if the at-risk patient population was identified with strategies to address at risk patient needs responded "No, I don't believe so."

Based on interview and review of the facility's Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies and procedures were developed based on the risk assessment. This failure had the potential to negatively affect the current patients and/or staff in the facility in the event of an emergency.

Findings include:

During a review of the facility EPP on 11/08/2023 at 1:56 PM, with the Director of Plant Operations (DPO), no documentation was found to show the EPP was developed from the risk assessment.

During an interview on 11/08/2023 at 2:22 PM, the Director of Plant Operations confirmed there was no risk assessment.

Based on interview and review of the facility's Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies addressed the subsistence needs of food and pharmaceuticals for the patients and staff in an emergency event. This failure had the potential to affect the current patients receiving care at the facility and any outpatients that are receiving care in the facility.

Findings include:

During a review of the facility EPP on 11/08/2023 at 1:56 PM, the Director of Plant Operations (DPO), revealed there was no policy or procedure regarding food and pharmaceutical subsistence needs of staff and patients listed during an emergent event.

During an interview on 11/08/2023 at 2:28 PM, the Director of Plant Operations confirmed the food and pharmaceutical needs were not addressed.

Based on interview and review of the facility's Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies addressed a system of tracking for staff and sheltered patients during an emergent event. This failure had the potential to affect the current patients receiving care in the facility, any outpatients that receiving care in the facility, and facility staff present.

Findings include:

During a review of the facility EPP on 11/08/2023 at 1:56 PM with the Director of Plant Operations, no policy, procedure, or tracking system was located in the emergency plan.

Review of the facility "Emergency Operations Plan" on page 35 was:
"-Patient Tracking: Internal and External
In departments that may receive disaster patients, such as the Emergency Department and patient care units, via transfers from another facility or campus locations, patient trackers will be assigned to track the patients entering and leaving the areas. . .. The form used for patient tracking will be the . . . -Disaster Victim Patient Tracking Form." [sic]

During an interview on 11/08/2023 at 2:31 PM, the Director of Plant Operations stated, "We do not have this tracking system currently."

Based on interview and review of the facility's Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP addressed a plan for the safe evacuation of the facility. This failure had the potential to affect the current patients receiving care in the facility, any outpatients receiving care in the facility, and staff working at the time an evacuation may be required.

Findings include:

During a review of the facility EPP on 11/08/2023 at 1:56 PM with the Director of Plant Operations, no policy or procedures regarding safe evacuation from the facility was located in the emergency plan.

Review of page 34 of 38 of the facility "Emergency Operations Plan" showed:
"Managing Patient Clinical and Support Activities . . .
Evacuation Activities
-An evacuation of the hospital for a situation that renders the facility no longer capable of providing the necessary support for patient care, treatment, and services, should be directed by the Incident Commander. The evacuation should be handled in cooperation with local police or fire and/or local . . ..
-The local police or fires and/or EOC [sic] should be notified as soon as the potential for evacuation is considered and should be kept updated on an ongoing basis in order to begin the process for identification of the availability of vehicles to relocate the patients.
Procedures utilized during an evacuation process are identified in the hospital Evacuation Plan. Patient location will be using a Master Evacuation Tracing Form . . ."

During an interview on 11/08/2023 at 2:34 PM, the Director of Plant Operations stated, "[Evacuation procedures are] Not included right now."

Based on interview and review of the facility's Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies addressed procedures for sheltering in place for patients, staff, visitors, and/or outpatients present during an emergency event. This failure had the potential to affect the current patients receiving care in the facility and any outpatients that are receiving care in the facility.

Findings include:

During a review of the facility EPP on 11/08/2023 at 1:56 PM with the Director of Plant Operations, there was no policy or procedures regarding the sheltering in place for anyone in the facility during an emergent event.

During an interview on 11/08/2023 at 2:35 PM regarding procedures for sheltering in place, the Director of Plant Operations, "Nothing regarding sheltering in place is in there."

Based on interview and a review of the facility Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to identify a system of medical documentation that preserves patient information, protects the confidentiality of patient information, secures, and maintains the availability of patient records. This failure had the potential to affect the current patients receiving care in the facility and/or any outpatients receiving treatment in the facility.

Findings include:

Review of the facility EPP on 11/08/23 at 1:56 PM with the Director of Plant Operations did not reveal any policy or procedure that identifies the system of medical documentation that preserves resident information; provides for the confidentiality of resident information; and secures, maintains, the availability of resident records in the case of an emergent event.

In an interview on 11/08/23 at 1:56 PM, when asked if the EPP included a policy or procedure that addressed a medical record system that secured and maintained the availability of patient records, the Director of Plant Operations responded "No."

Based on interview and review of the facility's Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies addressed the use of federal or state healthcare volunteers to meet staffing requirements during an emergency event. This failure had the potential to affect the current patients receiving care in the facility and any outpatients that are receiving care in the facility.

Findings include:

Review of the facility's EPP revealed no policy inclusion regarding the use of State and/or Federal healthcare professional volunteers in an emergency, or other emergency staffing strategies.

On pages 35 and 36 of 38 of the facility "Emergency Operations Plan" showed:
"Disaster Privileges
-Volunteer Licensed Independent Practitioners (LIP)
The hospital grants disaster privileges to volunteer licensed independent practitioners (LIP) when the Emergency Operations Plan has been activated . . . The policy and procedure identifying the hospitals' management of this process is located in the Valley Health System Policy: Medical Staff Disaster Privileges. We don't have this policy - you will need to attain this policy from . . . and assure that it is appropriate for DVH based on medical staff guidelines.
-Other Licensed Volunteers
The hospital assigns disaster responsibilities . . . The policy on Other Licensed Volunteers is the Valley Health System Licensure/Certification/Registration Policy.

During an interview on 11/08/2023 at 2:40 PM regarding federal and state healthcare volunteers, the Director of Plant Operations stated, "No current policy."

Based on interview and review of the facility's Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the Critical Access Hospital (CAH) failed to maintain a current list of names and contact information in the "Emergency Preparedness Communication Plan" that included all facility staff members and patient physicians. This failure had the potential to affect the patients receiving care in the facility and could delay the facility's ability to respond to an emergency.

Findings include:

Review of the facility's EPP Communication Plan on 11/08/2023 at 1:56 PM with the Director of Plant Operations showed the plan did not include identification of all the facility's staff and their contact information (only administrative staff were identified), nor did it include a list of patient physicians and their contact information.

In an interview on 11/08/2023 at 2:48 PM, the Director of Plant Operations confirmed only facility administrative staff were identified. When asked about the inclusion of patient physicians contact information, the Director of Plant Operations stated, "No."

Based on interview and review of the facility's Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP communication plan addressed the means of communicating with the federal and state emergency management agencies. This failure had the potential to affect the current patients receiving care in the facility, any outpatients that receiving care in the facility, and hindered the facility's ability to prepare for potential emergency situations.

Findings include:

Review of the facility EPP Communications Plan on 11/08/2023 at 1:56 PM with the Director of Plant Operations did not reveal primary and alternate methods of communication with the federal and state emergency management agencies.

In an interview on 11/08/2023 at 2:51 PM the Director of Plant Operations confirmed the federal and state emergency management agencies were not included, stating, "I don't believe so."

Based on interview and review of the facility's Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP Communication Plan included written a written policy or procedure that addressed the sharing of information and medical documentation for patients under the facility care. This failure had the potential to affect the current patients receiving care in the facility and any outpatients that receive care in the facility.

Findings include:

A review of the facility's EPP communication plan on 11/08/2023 at 1:56 PM with the Director of Plant Operations did not show a written policy or procedure for the sharing of patient information and medical documentation with another provider in an emergent event.

In an interview on 11/08/2023 at 2:54 PM, the Director of Plant Operations confirmed there was no identified method for sharing information and/or medical documentation in writing in the EPP, stating, "No, [it's] not addressed."

Based on interview and review of the facility's documentation, the facility failed to ensure the Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP) documented an annual community based full scale exercises to test the EPP; or the documentation of facility efforts to identify a full-scale community-based exercise; or an individual facility based functional exercise twice a year. This failure had the potential to affect current patients, any outpatients receiving treatments, staff, volunteers, or visitors in the facility in an emergent event.

Findings include:

Review of the facility EPP on 11/08/2023 at 1:56 PM with the Director of Plant Operations did not reveal any documentation of facility participation in community or facility-based exercises to test their emergency plan.

During an interview on 11/08/2023 at 2:57 PM regarding the exercises, the Director of Plant Operations had been there about a year, and they have not had an emergency exercise.