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Based on review of the facility's policy/procedure, personnel files, and interviews, it was determined that the facility failed to require that a personnel member completed a skill's specific competency prior to providing direct patient care. This deficient practice poses a potential risk to the health and safety of the patients, when newly hired personnel, are not trained, and evaluated to ensure competency prior to providing direct patient care.

Findings include:

Policy titled "Competency Assessment" (#HR-035; 08/23/2017), revealed: "...policy of Mt. Graham Regional Medical Center to assess the competency of all employees...competency is the application of knowledge...skills...purpose of skills/competency assessment is to...provide a mechanism for directing and evaluating the skills/competency needed by employees to provide quality healthcare services...competency will be assessed on a continuum throughout the employment...continuum will include assessment during the hiring process, initial competencies during the orientation...initial competency assessment will include validation of...principal clinical/technical duties (core job functions)...functions and accountabilities...high risk job functions and accountabilities...the manager will validate that the employee has successfully completed this process...if successful completion has not been achieved by the end of the initial orientation period the employee is not yet deemed competent, and an action plan is initiated...."

Personnel File review conducted 08/27/2020, revealed the following:

i. Nineteen (19) out of twenty (20) personnel files reviewed for Personnel #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, and #27, confirmed no documented evidence of the personnel's skills orientation competency, specific for the personnel's job title.

Personnel #4, and Personnel #38 both confirmed during a combined interview conducted 08/27/2020 (1030), that most of the personnel files reviewed had documented evidence of the hospital's Human Resources orientation, but that nineteen (19) personnel files had no documented evidence of the personnel's orientation skills competency.

Based on review of facility documents, and interviews, it was determined that the Governing Body failed to require that Medical Staff By-Laws and Rules & Regulations were reviewed, and approved once every three (3) years. This deficient practice poses a potential risk to the health and safety of patients, when the Medical Staff does not review the ByLaws and/or Rules & Regulations to ensure that requirements are current, and according to any State and/or Federal regulations.

Findings include:

Document titled "Amended & Restated ByLaws of Mt. Graham Regional Medical Center" (08/14/2012), revealed: "...Article II...Purposes...the Corporation shall have the following specific purposes...to meet the healthcare needs...to provide patients admitted or treated at the Medical Center, Cancer/Ambulatory Care Center...Rural Health Clinic and any other services of the Corporation, and any affiliates of the Corporation, with healthcare in compliance with federal, state, and local regulations...to provide facilities that will permit safe working conditions, equipment, policies and procedures for patients, medical staff, and employees...Article III...Membership...Section 3...Powers and Duties of the Board of Directors...shall manage the affairs of the Corporation including subsidiaries and affiliates controlled by the Corporation...Article VIII...Medical Staff...Medical Staff ByLaws and Rules & Regulations shall be adopted by the Medical Staff and approved by the Board before becoming effective...."

Document titled "Medical Staff ByLaws, Policies, and Rules & Regulations of Mt. Graham Regional Medical Center", revealed effective dates of 04/04/2011, and 06/14/2011, with no documented evidence of additional dates of approval.

Document review of Governing Body and Medical Executive Committee Meeting Minutes, conducted 08/25/2020 - 08/26/2020, revealed the following:

i. Governing Body Minutes: 07/09/2019; 08/13/2019; 09/10/2019; 10/08/2019; 11/12/2019; 12/20/2019; 01/14/2020; 02/11/2020; 03/10/2020; 04/14/2020; 05/12/2020; 06/09/2020, and 07/14/2020, revealed no documented evidence of approval of Medical Staff ByLaws and/or Rules and Regulations;

ii. Medical Executive Committee Minutes: 05/07/2019; 06/04/2019; 08/06/2019; 10/01/2019; 11/19/2019; 1/07/2020; 02/04/2020; 03/03/2020; 04/07/2020; 06/02/2020; 07/07/2020, and 07/13/2020, revealed no documented evidence of review and/or approval of Medical Staff ByLaws and/or Rules and Regulations to send to the Governing Body.

Personnel #1 confirmed during an interview conducted 08/26/2020 (1130), that two (2) physicians attend the Governing Body meetings. Additionally, Personnel #1 revealed that to his/her knowledge, the Medical Staff ByLaws and/or Rules and Regulations have not been sent for approval to the Governing Body.

Provider #13 confirmed during an interview conducted 08/26/2020 (1530), that s/he attends the Governing Body meetings. Additionally, Provider #13 revealed that the Medical Executive Committee is currently reviewing the Medical Staff ByLaws and/or Rules and Regulations to send to the Governing Body for approval, but the Medical Staff ByLaws and/or Rules and Regulations have not yet been sent.

Based on review of the facility's documents, and interviews, it was determined that the facility failed to require that contracted services were reviewed, and evaluated on an annual basis. This deficient practice poses a potential risk to the health and safety of the patients, when external contracted services providing patient care, or impacting patient care, and services are not reviewed on an annual basis.

Findings include:

Document titled "Amended & Restated ByLaws of Mt. Graham Regional Medical Center" (08/14/2012), revealed: "...Article II...Purposes...the Corporation shall have the following specific purposes...to meet the healthcare needs...to provide patients admitted or treated at the Medical Center, Cancer/Ambulatory Care Center...Rural Health Clinic and any other services of the Corporation, and any affiliates of the Corporation, with healthcare in compliance with federal, state, and local regulations...to provide facilities that will permit safe working conditions, equipment, policies and procedures for patients, medical staff, and employees...Article III...Membership...Section 3...Powers and Duties of the Board of Directors...shall manage the affairs of the Corporation including subsidiaries and affiliates controlled by the Corporation...."

Document titled "Quality Assurance & Process Improvement Plan" (03/2019), revealed: "...provides a framework for an integrated and comprehensive program to monitor, assess, and improve the quality and safety of patient care delivered...committed to the provision of quality health care...to the concept of continuous improvement of hospital operations and patient care...ultimate responsibility for quality of care provided at Mt. Graham Regional Medical Center rests with the Board of Directors....effectiveness of the Performance Improvement Program is evaluated annually...outcomes of the Program's evaluation are reported to the Board of Directors...."

Document (not titled/not dated) review conducted 08/26/2020, with headers titled: "Contract Name, Department, Service/Product, Reviewed By, Reviewed Date, and Ready to File", revealed the following:

i. A total of seventy-six (76) contract/vendor names were list, in which forty-five (45) contract/vendors showed no documented evidence that the contract/vendor had been reviewed.

Document review of Governing Body, Quality Council, and Quality Governance Meeting Minutes, conducted 08/25/2020 - 08/26/2020, revealed the following:

i. Governing Body Minutes: 07/09/2019; 08/13/2019; 09/10/2019; 10/08/2019; 11/12/2019; 12/20/2019; 01/14/2020; 02/11/2020; 03/10/2020; 04/14/2020; 05/12/2020; 06/09/2020, and 07/14/2020, revealed no documented evidence of an annual review and/or approval of Contracted Services;

ii. Quality Council Minutes: 02/05/2019; 05/02/2019; 07/30/2019; 11/04/2019; 02/20/2020, and 07/07/2020, revealed no documented evidence of an annual review of Contracted Services;

iii. Quality Governance Minutes: 07/23/2019; 09/03/2019; 01/28/2020; 06/08/2020; and 07/23/2020, revealed no documented evidence of an annual review of Contracted Services.

Personnel #2 confirmed during an interview conducted 08/27/2020 (1130), that neither the Quality Council or Quality Governance committees had reviewed the contract/vendor list within the past year.

Personnel #1 confirmed during an interview conducted 08/26/2020 (1025), that Quality Council sends reports to the Governing Body for review, but to his/her knowledge, that the annual evaluation/review of the contract/vendor list had not been completed, and that the contract/vendor list is currently in the process of review.

Based on review of facility policies/procedures, documents, and interviews, it was determined that the facility failed to that require that dishwasher temperature checks were done prior to each wash cycle, for breakfast, lunch and dinner. This deficient practice poses a potential risk to the health and safety of the patients, when the facility cannot demonstrate health requirements for properly sanitizing dishes/utensils used when serving food to patients, staff, providers, and guests.

Findings include:

Policy titled "Temperature Documentation" (#DT-047; 04/15/2016), revealed: "...temperatures will be documented to ensure high level of food safety, and sanitation in compliance with state regulations...dishwasher employee will record the dish machine temperature each day...any unacceptable temperature will be reported to the supervisor on duty for corrective action...a temperature out of range will be rechecked later in the day to determine if it has improved or action needs to be take...if action is necessary, supervisor on duty will be informed...."

Policy titled "Food Storage Under Proper Conditions" (#DT-029; 05/01/2020), revealed: "...compliance reflects the following...Dish Machine Temperature Logs...temperatures are documented for all three (3) meals...appropriate actions have been taken and documented when standards are not met...."

Document titled "Dish Machine Temperature Log", revealed the following:

i. Temperature log for dishwasher, showed missing control temperature checks for: July 2020 (ten (10) missing), 08/22/2020 (three (3) missing), and 08/23/2020 (three (3) missing).

Personnel #31 confirmed during an interview conducted 08/25/2020 (1245), that there were ten (10) missing dishwasher temperature control checks missing for July 2020, and three (3) dishwasher temperature control checks for each day on 08/22/2020, and 08/23/2020. Additionally, Personnel #1 revealed that dishwasher temperature control checks are to be done three (3) times daily prior to each wash cycle, and documented on the dishwasher temperature log.

Based on review of the facility's policy/procedure, document and interviews, it was determined that the facility failed to require that evacuation drills were completed at least once, every twelve (12) months for the six (6) Single Group License (SGL's) clinics. This deficient practice poses a potential risk to the health and safety of the patients, when the facility does not train staff how to properly evacuate the clinic in the event of an emergency, and that the evacuation is conducted, evaluated, and documented to verify compliance.

Findings include:

Policy titled "Safety Orientation Education" (#HR-099; 08/23/2017), revealed: "...policy applies to Mt. Graham Regional Medical Center employees...safety education is a high priority for all staff...New Hire Orientation process is to familiarize staff members with their jobs...with the work environment before the staff member begins patient care...fire/safety drills are conducted during the calendar year...employee participation is mandatory...in-service attendance records maintained in each department should reflect attendance...and participation in appropriate fire and disaster drills...."

Document titled "Fire Safety Management Plan" (12/2017), revealed: "...Mt. Graham Regional Medical Center is committed to the provision of quality health care...to the maintenance of a safe environment...on-going coordinate effort to protect building occupants from fire...organization-wide effort involving and impacting all aspects of the hospital's operations...ultimate responsibility for the Fire Safety Management plan...rests with the Board of Directors...Environment of Care Chair...authorized to take...action...to address deficiencies...compliance with law and regulation...continuous fire safety training...fire prevention and response training includes...response to the fire...evacuation of patients...CEO receives regular reports on the activities of the Fire Safety Program from the EOC Committee...."

Evacuation drill documentation for the six (6) SGL's was requested on 08/24/2020, and was not provided.

Personnel #8 confirmed during an interview conducted 08/24/2020 (1230), that the clinic has had a fire drill, but that the fire alarm sounded, and everyone stayed inside.

Personnel #28 confirmed during an interview conducted 08/25/2020 (1605), that fire alarm/drills have been completed annually at the six (6) clinics (SGL's), but that no evacuation drill has been conducted within the past twelve (12) months.

Based on review of the facility's policies/procedures, documents, observations on tour, and interviews, it was determined that the facility failed to require that expired supplies, used for patient care were discarded and not used after the expiration date. This deficient practice poses a risk to the health and safety of the patients, when the facility fails to monitor the outdates of supplies, with the potential of expired supplies to be used on patients causing harm.

Findings include:

Policy titled "Materials Management" (#MM-014; 11/2015), revealed: "...applies to all inventories managed by Materials Management...unusable items...expiration of sterile shelf life/packaging integrity...."

Policy titled "Crash Cart Monitoring" (#NPC-204; 02/2014), revealed: "...crash carts will be checked and monitored by Nursing and Pharmacy staff on a regularly scheduled basis per each department's protocol...all departments with a crash cart will check the crash cart at least once daily during the days of operation and after each use...if any supplies are near expiration date...place a piece of tape on the drawer and write on the tape the date of expiration and the item...."

Policy titled "Emergency and Urgent Medication" (#PHA-011; 05/17/2016), revealed: "...policy applies to clinical staff at Mt. Graham Regional Medical Center who are involved in the supply, preparation, therapeutic use, and management of medication used in urgent and medical emergencies...Code Carts will be stocked with medication and supplies as deemed necessary...adequate life support supplies and equipment should be readily available...on all nursing units and ancillary areas at all times...nurse in charge of the day shift will assign a responsible staff person to check the Code Cart...in the Emergency Room this procedure is done two (2) times every twenty-four (24) hours...Code Cart must be checked within the first hour of duty...."

Policy titled "Quality Improvement Policy" (#QUA-002; 11/28/2017), revealed: "...policy applies to all departments and affiliated entities operating under its single group license...and Copper Mountain Clinic...MGRMC will ensure that all services provided are consistent with accepted standards of practice...shall be written policies and procedures outlining the operation of the...service...will assist departments and affiliated entities...in measuring and monitoring quality outcomes, and implementing appropriate changes...QAPI program includes process for collecting, measuring, analyzing and tracking relevant data...related to patient care...all MGRMC staff are accountable and responsible for the quality of care and services within their respective departments...performance improvement activities focus on...problem-prone areas that affect care outcomes, patient safety...."

Document titled "Infection Control Plan" (11/2018), revealed: "...the infection control program...is an organization-wide effort involving and impacting all aspects of the hosptial's operation, and requiring the active participation, cooperation, and commitment of all persons...ultimate responsibility for the infection control program...rests with the Board of Directors...comprehensive infection surveillance is conducted on a regular and on-going basis...areas of surveillance include...compliance with infection prevention practices...at the time of hire and annually...staff are oriented to concepts of infection control and prevention...."

Observations on tour conducted 08/24/2020 - 08/27/2020, throughout the hospital presses, and Single Group License (SGL) entities revealed the following:

i. A total of two-hundred sixty-nine (269) expired supplies, with outdates ranging from 06/2007 through 07/2020 were found. Ninety-one (91) out of the two-hundred sixty-nine (269) expired outdates were found in Operating Room #4. The expired supplies were collected and given to Personnel #2.
Personnel #3 confirmed during observations on tour conducted 08/24/2020 - 08/27/2020, throughout the hospital premises, and SGL entities, that the identified supplies were expired.