This is the only survey for this facility

The facility Emergency Plan (the Plan) has been revised to include language that addresses:
- Unique vulnerabilities of the Patient Population (Section: A. III, page 4) as follows:
"The facility provides outpatient services to an adult patient population from age 18 and above. Unique vulnerabilities of this population include:
- Mobility limitations (wheelchair bound)
- Hearing Impairment
- Vision Impairment
- Mentation limitations"

- Types of services the clinic would be able to provide in an emergency (Section: B. IV, pages 8 and 9)
"Depending on the type of emergency, services may be:
- Continued
- Curtailed
- Restricted
In the event that an emergency results in the facility's inability to provide any services, clients will be notified by phone of this situation and offered alternative medical resources.

(Please reference the Emergency Plans in Section C of this plan for services that will be provided during different types of emergencies)."

- Insertion of Organizational Chart designating lines of authority (Section A. V, page 6)
An organizational chart identifying the command structure for delegation of authority has been added to the plan. This structure includes the Incident Commander as leader for the direction of all assignments and management of the event. There are five emergency operations positions reporting to the Incident Commander including: Communications, Client Liaison, Facility and Environmental Coordinator, Client Resource and Supply Coordinator and Medical Care and Triage Coordinator. These positions are appointed by the Incident Commander as needed at the time of the event. Each of these five positions has the authority to enlist additional staff resources to assist with the position responsibilities.

The Incident Commander position is assumed by the Office Manager. In the event of the Office Manager's absence, the following order of succession will be followed:
o Staff RN
o Senior Medical Assistant
o Receptionist

- Incident Command Responsibility Assignment and Backup Designation (Section A. V, page 6)
Same as provided above under the response to the insertion of the organizational chart.
- Staging Area Coordinator Assignment and Backup Designation (this Assignment was eliminated and duties included in other assignments)
- Staff Member responsible for taking Emergency Operations Plan with staff schedules in the event of an evacuation (this assignment is now included in specific job titles)
Revisions to the Plan were completed on March 12, 2018.
These job duty assignments and job descriptions will be included in Plan "Section C. Procedures". Each Emergency scenario will delineate the specific job duties assigned to each role in the " Incident Command Delegation of Authority flow diagram" (Section: A. V, page 6). The Plan will be kept in the reception area and will be accessible to all staff.
Staff categories assigned to these roles and responsibilities will be educated on duty requirements during the mandatory staff in-service conducted by the Safety Coordinator by March 31, 2018. Evaluation of staff knowledge regarding specific roles will be assessed by post-education testing completed the same date.
Monitoring will be accomplished through periodic drills (at least annually) to determine staff knowledge of and ability to perform specific assigned roles and duties. Performance will be evaluated and the need for any additional education will be determined based on any identified issues.

Safety Coordinator is responsible for enactment of the plan.

The facility Emergency Operations Plan was revised to include language that addresses collaborative and cooperative planning efforts (Section A. IV, page 5) as follows:
"The organization cooperates and collaborates with the Armstrong County Emergency Management Agency to maintain an integrated response during a disaster situation. The Safety Coordinator is a member of the Healthcare Coalition of Southwestern Pennsylvania that supports collaboration with all healthcare facilities in the region. This local and regional coalition provides for emergency resources needed during disaster situations including but not limited to:
- Staffing resources
- Medication
- Personal Protective Equipment
- Decontamination Supplies and Equipment
- Medical Supplies
In addition to Emergency resources the coalition provides emergency preparedness education and training to members and affiliates. Regional drills and exercises are conducted at least annually with all members participating.
State and Federal emergency preparedness coordination is facilitated by the local/regional emergency management agencies. As members of the coalition, the organization participates as required."

These revisions were completed on March 12, 2018.
- Monitoring is accomplished by reviewing documented facility participation in coalition meetings and local/regional drills and trainings at least annually. Compliance will be monitored by the Director of Risk and Quality Management.
Safety Coordinator is the person responsible for this plan

The facility Emergency Preparedness Plan was amended to include language that addresses individual patient care and treatment needs to ensure safe evacuation (Section: B, III (a-h), page 7 and 8) as follows:
a. There are a number of hazards that could cause an evacuation. The most common would be a fire in or near the facility, rising flood waters or an evacuation order issued by the police, fire department or other government authority.

b. Evacuation maps are posted in all patient rooms, offices and waiting areas.

c. All exits are identified by illuminated exit signs.

d. In the event that evacuation is deemed necessary, the incident commander will order the evacuation.

e. The Incident Commander directs the Communication Coordinator (position # 1 on the organization chart) to call 911 and the ACMH switchboard. ACMH switchboard will contact other appropriate personnel.

f. The Incident Commander will direct the "Client Liaison" position #2 on the organization chart to coordinate an assessment of the client and visitor population on site at the time of the emergency to determine any specific evacuation needs based on individual patient vulnerabilities. The Client Liaison will take possession of the daily patient schedule, employee roster and log any visitors on site. As needed the Client Liaison position will direct other staff members to assist with evacuation of any individuals who need additional assistance. Based on the plan vulnerability analysis, this may include patients with no or limited mobility, vision or hearing impaired or those with varying degrees of mentation limitation. The Medical Care and Triage coordinator (position # 5 on the organizational chart) will be engaged as needed to triage and provide medical care for any client, visitor or staff who has sustained injury during the emergency situation. Staff will be assigned to provide available equipment necessary for evacuation of those clients or visitors with limited mobility. Wheelchairs will be available for this purpose (clients with their own wheelchair will be evacuated using this equipment; there will also be one additional wheelchair available on site if needed). The Client Liaison will be responsible for assuring that all clients and visitors are directed to the assembly area designated by the office Incident Commander and/or the responding local Emergency Services Chief.

g. Post evacuation, the clients, visitors and staff will report to the assembly area located in suite 230 across the street from the clinic.

h. The Client Liaison position, utilizing the comprehensive patient, visitor and staff list, will verify that all identified individuals are accounted for either at the assembly area or by documenting their location.

Plan revisions were completed by March 13, 2018.
Staff categories assigned to these roles and responsibilities will be educated on duty requirements during the mandatory staff in-service conducted by the Safety Coordinator by March 31, 2018. Evaluation of staff knowledge regarding specific roles will be assessed by post-education testing completed the same date.
Monitoring will be accomplished through periodic drills (at least annually) to determine staff knowledge of and ability to perform specific assigned roles and duties. Performance will be evaluated and the need for any additional education will be determined based on any identified issues.
Safety Coordinator is responsible for enactment of the plan.

The Emergency Operation Plan was revised to include language that further defines the "Shelter in Place" procedure (Section: B II, (a-f), page 7) as follows:
a. "Shelter in place means that the staff, clients and visitors will remain in the building. Sheltering in place can be used due to severe storms, tornados, and violence/terrorism or hazard materials conditions in the area.
b. As this is a medical health clinic with limited visitor sustenance resources, the duration of Shelter in Place is estimated to be approximately 4 hours. If the emergency situation extends beyond 4 hours the Incident Command staff will take appropriate measure to transfer clients, visitors or staff in need of additional care.
c. There will be water and toilet facilities readily available. If any individual requires food, medicines or other medical resources every effort will be made to transfer the person to the nearest hospital.
d. If sheltering in place is result of a weather emergency that requires avoidance of windows and doors, staff, clients and visitors will move to interior rooms and hallways.
e. If sheltering is used in the event of a hazardous chemical incident, windows and doors will be shut and all fans, air conditioners, ventilators will be turned off.
a. The facility will stay in shelter until authorities give an all clear or the emergency threat has ended as determined by the incident commander."

Plan revisions were completed by March 13, 2018.
Staff categories assigned to these roles and responsibilities will be educated on duty requirements during the mandatory staff in-service conducted by the Safety Coordinator by March 31, 2018. Evaluation of staff knowledge regarding specific roles will be assessed by post-education testing completed the same date.
Monitoring will be accomplished through periodic drills (at least annually) to determine staff knowledge of and ability to perform specific assigned roles and duties. Performance will be evaluated and the need for any additional education will be determined based on any identified issues.
Safety Coordinator is responsible for enactment of the plan.

The emergency operations plan was revised to include language that further defines preserving patient information, protecting confidentiality of patient information and secures and maintains availability of records.
In the event of computer down time a paper progress record has been developed to include the following:
- Patient name and DOB
- Chief Complaints
- HPI
- Current Medications
- Allergies
- Family History
- Social History
- ROS
- Vital Signs
- Examination
- Assessment
- Treatment Plan
- Procedures
- Immunizations
- Next Appointment
- Billing Information

As this is a medical health clinic employing a maximum of three (3) providers a determination was made, based on historical patient load data, to have 60 printed paper progress records available in the event of an emergency. Blank copies of this progress record are stored in a designated file in the receptionist area of the office.
Monitoring to ensure the quantity of (60) progress notes is present is the responsibility of Receptionist A. This will be confirmed by a monthly inspection and recorded on a monthly inspection sheet. The practice manager will ensure this process has been followed and initial the monthly inspection sheet. This monitoring will begin by 4/6/18. This evaluation process will be sustained annually with no end date.
Once this progress record is completed by the provider it will be stored in a locked file cabinet in the manager's office until the computer system would be functional again and the record could be scanned into the system and then shredded. In the event the patient must be transferred out of the clinic with the progress note the progress note will be placed in a sealed confidential envelope and given directly to the emergency transporter.
If access to records is required in an emergency situation the ACMH Medical Records department has access to the clinics electronic health record and records can be obtained through them.
Anytime that the emergency medical documentation plan is implemented a debriefing will occur with the office coordinator and medical director and other staff as needed to review the process and ensure that the process functioned adequately. If there was a failure in the process then revisions will be made to correct the problem. If the emergency medical documentation plan is put in process, then the process review team, including the RHC medical director, the chief medical director, physician, APP and the practice manager will conduct a record review of the paper progress note. This review will include utilization of best practice resources, completeness of documentation addressing the patient visit, compliance with ordering and administration of procedures and all follow up care and treatment. Five paper progress notes will be chosen at random to be reviewed. Audit deficiencies will be identified, recorded and addressed with the process review team committee, and practitioners will receive additional education as needed. The office coordinator will be responsible for ensuring that these debriefings take place and any necessary corrections and staff re-education occurs. Evidence of re-education will be documented.
The procedures for the emergency medical documentation plan will be reviewed at the annual rural health office meeting. The blank progress notes will be reviewed at that time to determine that adequate categories of documentation are being captured on the note and to make any changes that the committee recommends.
Staff categories assigned to these roles and responsibilities will be educated on duty requirements during the mandatory staff in-service conducted by the Safety Coordinator by April 6, 2018. Evaluation of staff knowledge regarding specific roles will be assessed by post-education testing completed the same date.
Monitoring will be accomplished through periodic drills (at least annually) to determine staff knowledge of and ability to perform specific assigned roles and duties. Performance will be evaluated and the need for any additional education will be determined based on any identified issues. The drills will be conducted by the Safety Coordinator.
The Safety Coordinator is responsible for this plan.

The Emergency Operations Plan has been amended to include language addressing the use of additional resources and volunteers (Section: B VII, page 11 & 12) as follows:
a. Human Resources
If additional personnel are needed to support management of the emergency situation, the RHC Operations Manager will be contacted to pull clinical and non-clinical resources from other RHC's and or physician office practices to assist. Emergency 911 will be contacted for additional medical resources. The Healthcare Coalition of Southwest Pennsylvania will be contacted to integrate any supportive services from State and Federal designated health care professional resources if needed.
b. Volunteers
Non-medical volunteers who respond to an emergency situation will be directed and assigned by the Client and Resource Supply Coordinator, position # 4 on the organization chart.
The Incident Commander and Client and Resource Supply Coordinator will be educated on their role in requesting additional resources during the mandatory staff in-service conducted by the Safety Coordinator by March 31, 2018. Evaluation of staff knowledge regarding specific roles will be assessed by post-education testing completed the same date.
Monitoring will be accomplished through periodic drills (at least annually) to determine staff knowledge of and ability to perform specific assigned roles and duties. Performance will be evaluated and the need for any additional education will be determined based on any identified issues.
Safety Coordinator is responsible for enactment of the plan.

The Emergency Operations Plan is amended to include a more comprehensive Communications Plan (Section: B VI, page(s) 9, 10 and 11) as follows:
"COMMUNICATION PLAN

a. External Communications
- In the event of a disaster requiring the assistance of local Emergency Management services, the Communications Coordinator (position#1 on the organization Chart) will contact the local Armstrong County Emergency Management Agency at 724-548-3431.
- In addition, when a disaster or emergency cannot be facilitated by the local Emergency Management Agency, that agency personnel will communicate to the Southwest Pennsylvania Healthcare Coalition via the PA Knowledge Center requesting additional support
- Communication Coordinator will contact the local Pennsylvania State Police at 724-543-2011 as necessary depending on the type of disaster.
- Communications Coordinator will contact the County Department of Public Health at 724-543-2700 and/or the PA State Department of Public Health at 717-787-4366 for any disasters associated with public health concerns.
- The local police, fire, and EMS contact information is provided for each RHC with their respective plan. The Communication Coordinator will contact these resources as necessary.
- The Communications Coordinator will address any requests for information, including local news or paper requests and provide briefings as appropriate and approved by the Incident Commander. As necessary, the Communications Coordinator will contact the ACMH hospital human resource vice president to verify any release of information to public entities.
- When an emergency includes utility disruption, the Communications Coordinator will contact the designated utility to notify them of the emergency and request assistance. The phone numbers for local utilities are included in each RHC plan as appropriate. If the land line phone system is out, the Incident Command staff will utilize cell phones to contact the utility and other emergency service resources.
- When necessary, the Communications Coordinator will contact the federal emergency management agency at 1-800-621-3362.
b. Internal Communications
- During an emergency, internal communications at the RHC will be coordinated by the Communications Coordinator who will assure that all other members of the team are kept informed of critical communication issues and needs.
c. Communication with Other Health Care Providers
- Care will be coordinated with other Health Care providers including but not limited to hospitals and Emergency Medical Services as appropriate and necessary based on the type of emergency. The Communications Liaison will contact these entities directly or indirectly through 911 as appropriate.
- ACMH is the closest hospital to all RHC's and would be contacted by calling 724-543-8500. The hospital switchboard operator will direct the call to the necessary department or service based on need.
- Local EMS is contacted via Armstrong County 911.

d. Communication with Clients and Visitors
- The Communication Coordinator will enlist additional staff to notify scheduled clients of the need to cancel and reschedule appointment or otherwise direct them to appropriate care.
- The Communication Coordinator or designee will contact any scheduled visitors to inform them of the emergency situation."

Plan revisions were completed by March 13, 2018.
Staff categories assigned to these roles and responsibilities will be educated on duty requirements during the mandatory staff in-service conducted by the Safety Coordinator by March 31, 2018. Evaluation of staff knowledge regarding specific roles will be assessed by post-education testing completed the same date.
Monitoring will be accomplished through periodic drills (at least annually) to determine staff knowledge of and ability to perform specific assigned roles and duties. Performance will be evaluated and the need for any additional education will be determined based on any identified issues.
Safety Coordinator is responsible for enactment of the plan.

The Emergency Operations Plan is amended to include a more comprehensive Communications Plan (Section: B VI, page(s) 9, 10 and 11) as follows:
"COMMUNICATION PLAN

Intent:

The RHC Communication Plan will provide a mechanism for communicating information about the facility's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee.
.
a. External Communications
- In the event of a disaster, when the RHC requires the assistance of local Emergency Management services for assistance with medical transfers, evacuation or medical supplies, the Communications Coordinator (position#1 on the organization Chart) will contact the local Armstrong County Emergency Management Agency at 724-548-3431.
- In addition, when a disaster or emergency cannot be facilitated by the local Emergency Management Agency, that agency personnel will communicate to the Southwest Pennsylvania Healthcare Coalition via the PA Knowledge Center requesting additional support
- Communication Coordinator will contact the local Pennsylvania State Police at 724-543-2011 as necessary depending on the type of disaster.
- Communications Coordinator will contact the County Department of Public Health at 724-543-2700 and/or the PA State Department of Public Health at 717-787-4366 for any disasters associated with public health concerns.
- The local police, fire, and EMS contact information is provided for each RHC with their respective plan. The Communication Coordinator will contact these resources as necessary.
- The Communications Coordinator will address any requests for information, including request for client condition or location and/or local news or paper requests. For inquiries regarding the status or location of a client, the Communications Coordinator will verify that the caller can identify the patient date of birth that is included on the daily visit report. The caller will be given general status of the patient and any transfer location. As necessary, the Communications Coordinator will contact the ACMH hospital human resource vice president to verify any release of information to public entities.
- When an emergency includes utility disruption, the Communications Coordinator will contact the designated utility to notify them of the emergency and request assistance. The phone numbers for local utilities are included in each RHC plan as appropriate. If the land line phone system is out, the Incident Command staff will utilize cell phones to contact the utility and other emergency service resources.
- When necessary, the Communications Coordinator will contact the federal emergency management agency at 1-800-621-3362.
- During a disaster event that impacts the community surrounding the RHC, the Communications Coordinator will notify local Emergency Management agency at 724-548-3431 to provide the RHC's capacity and ability or inability to accommodate additional clients.
b. Internal Communications
- During an emergency, internal communications at the RHC will be coordinated by the Communications Coordinator who will assure that all other members of the team are kept informed of critical communication issues and needs.
c. Communication with Other Health Care Providers
- Care will be coordinated with other Health Care providers including but not limited to hospitals and Emergency Medical Services as appropriate and necessary based on the type of emergency. The Communications Liaison will contact these entities directly or indirectly through 911 as appropriate.
- ACMH is the closest hospital to all RHC's and would be contacted by calling 724-543-8500. The hospital switchboard operator will direct the call to the necessary department or service based on need.
- Local EMS is contacted via Armstrong County 911.

d. Communication with Clients and Visitors
a. The Communication Coordinator will enlist additional staff to notify scheduled clients of the need to cancel and reschedule appointment or otherwise direct them to appropriate care.
b. The Communication Coordinator or designee will contact any scheduled visitors to inform them of the emergency situation."

Plan revisions were completed by March 13, 2018.
Staff categories assigned to these roles and responsibilities will be educated on duty requirements during the mandatory staff in-service conducted by the Safety Coordinator by March 31, 2018. Evaluation of staff knowledge regarding specific roles will be assessed by post-education testing completed the same date.
Monitoring will be accomplished through periodic drills (at least annually) to determine staff knowledge of and ability to perform specific assigned roles and duties. Performance will be evaluated and the need for any additional education will be determined based on any identified issues.
Safety Coordinator is responsible for enactment of the plan.

The Emergency Operations Plan was amended to include language that addresses alternate means of communication with staff, federal, state, local, and regional emergency management agencies (Section: B VI, page 10) as follows:
- "When an emergency includes utility disruption, the Communications Coordinator will contact the designated utility to notify them of the emergency and request assistance. The phone numbers for local utilities are included in each RHC plan as appropriate. If the land line phone system is out, the Incident Command staff will utilize cell phones to contact the utility and other emergency service resources. In the event that cell service is not available, internet or email notification will be utilized to facilitate contact. When all means of communication are unavailable, the Incident Commander will identify a staff person to travel to the hospital to utilize emergency radio communication available to that site."

Plan revisions were completed by March 13, 2018.
Staff will be educated on Plan language and procedures during the mandatory staff in-service conducted by the Safety Coordinator by March 31, 2018. Evaluation of staff knowledge regarding specific roles will be assessed by post-education testing completed the same date.
Monitoring will be accomplished through periodic drills (at least annually) to determine staff knowledge of and ability to perform specific assigned roles and duties. Performance will be evaluated and the need for any additional education will be determined based on any identified issues.
Safety Coordinator is responsible for enactment of the plan.

The Emergency Operations Plan was amended to include language that addresses use and disclosure for disaster relief purposes, establishes requirements for disclosing patient information to public or private entity authorized by law or by charter to assist in disaster relief efforts for purposes of notifying family members, personal representatives or certain others of the patient's location or general condition. All disclosures will be made in compliance with HIPAA Privacy regulations at 45 CFR 164.510 (b)(4). (Section: B VI, page 10) as follows:
"Whenever possible during a disaster, patient consent will be obtained either verbally or in writing regarding disclosure of information to their representative(s). The Communications Coordinator will address any requests for information including those from public or private entity. For inquiries regarding the status or location of a client, the Communications Coordinator will provide general status and location information to the patient's identified representative. Any other disclosures will be dictated by the facilities charter in response to the disaster situation."

Plan revisions were completed by March 22, 2018.
The development of the Emergency Operations Plan provides the mechanism for assuring that any RHC patient on site during a disaster is provided with the best possible care, welfare, safety and security until emergency responders are available to assist or the disaster is abated. The RHC will be prepared to address a disaster via monitoring, evaluation and education demonstrated by the completion of at least two (02) disaster drills annually. Any time that the Emergency Operations plan is implemented a debriefing will occur with the office coordinator and medical director and other staff as needed to review the process and ensure that the plan functioned. If a failure occurred in the process, revisions will be made to correct the problem. These activities will assure that a problem with addressing a disaster does not occur in the future.
Staff will be educated on Plan roles and duties during the mandatory staff education conducted by the Safety Coordinator followed by a table top exercise by April 6, 2018. The Safety Coordinator will be responsible for ensuring that these debriefings take place and any necessary corrections and staff reeducation occurs. Evidence of reeducation will be documented. Evaluation of staff knowledge regarding specific roles will be assessed by post-education testing completed the same date.
Monitoring and sustainment will be accomplished through periodic drills (at least twice annually) to determine staff knowledge of and ability to perform specific assigned roles and duties. Performance will be evaluated and the need for any additional education will be determined based on any identified issues. This evaluation process will be sustained annually with no end date.
Safety Coordinator is responsible for enactment of the plan.

The Emergency Operations Plan was revised to include language that addressed the RHC's process for providing information regarding the clinic occupancy needs and its ability to provide assistance to the authority having jurisdiction (Section: B VI, pages 9 & 10) as follows:
"Intent:

The RHC Communication Plan will provide a mechanism for communicating information about the facility's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee.
.
a. External Communications
- In the event of a disaster, when the RHC requires the assistance of local Emergency Management services for assistance with medical transfers, evacuation or medical supplies, the Communications Coordinator (position#1 on the organization Chart) will contact the local Armstrong County Emergency Management Agency at 724-548-3431.
- During a disaster event that impacts the community surrounding the RHC, the Communications Coordinator will notify local Emergency Management agency at 724-548-3431 to provide the RHC's capacity and ability or inability to accommodate additional clients."

Plan revisions were completed by March 14, 2018.
Staff will be educated on Plan roles and duties during the mandatory staff in-service conducted by the Safety Coordinator by March 31, 2018. Evaluation of staff knowledge regarding specific roles will be assessed by post-education testing completed the same date.
Monitoring will be accomplished through periodic drills (at least annually) to determine staff knowledge of and ability to perform specific assigned roles and duties. Performance will be evaluated and the need for any additional education will be determined based on any identified issues.
Safety Coordinator is responsible for enactment of the plan.

The Emergency Operations Plan has been revised to include language that addresses initial and annual staff and physician training as well as documentation of all training (Section B VIII, page 12) as follows:
VII. "TRAINING, EVALUATIONAND TESTING
a. Physicians and staff will be provided annual education on the EOP during a mandatory in-service coordinated and conducted by the Safety Coordinator. Pre and post testing will be completed by all staff and physicians in order to assess knowledge of the plan.
b. All new physicians and staff will be trained on the EOP in orientation via an education training module. Staff will complete a read and sign documenting training. Post testing will be completed by the employee to demonstrate knowledge of the plan.
c. At least annually, the Safety Coordinator will conduct one emergency response exercise, testing the plan and staff compliance and knowledge with the plan. Additional exercise may be conducted based on newly identified vulnerabilities. These exercises will be observed, critiqued and corrective actions implemented for any deficiencies or gaps identified. Actions may include but not be limited to re-education of staff as needed.
d. Documentation of the initial EOP training the annual EOP training and staff participation in all exercises will be maintained by the Safety Coordinator and the Office Practice Manager."
Plan revisions were completed by March 14, 2018.
Monitoring will be completed by the Director of Risk and Quality Management verifying that"
- All new RHC hires have received education evidenced by sign-off
- All current staff have completed annual education evidenced by sign-off
- All employees have participate in at least one annual exercise
Monitoring will begin post staff education provided March 31, 2018 and conclude annually Monitoring will be documented on a compliance spreadsheet.
Safety Coordinator is responsible for enactment of the plan.

The Emergency Operations Plan has been revised to include language that addresses the annual exercise and testing of the EOP as well as documentation of all exercises (Section B VIII, page 12) as follows:
a. "At least twice annually, the Safety Coordinator will conduct emergency response exercises, testing the plan and staff compliance and knowledge with the plan. At least one exercise will be community based when possible. In addition, a facility specific exercise will be conducted annually. Any additional exercise may be conducted based on newly identified vulnerabilities. These exercises will be observed, critiqued and corrective actions implemented for any deficiencies or gaps identified. Actions may include but not be limited to re-education of staff as needed."
b. Documentation of the initial EOP training, the annual EOP training and staff participation in all exercises will be maintained by the Safety Coordinator and the Office Practice Manager."

In order to protect patients in the future as it relates to the individual we have developed an Emergency Operations Plan that provides the mechanism for assuring that any RHC patient on site during a disaster is provided the best possible care, welfare, safety and security until emergency responders are available to assist or the disaster is abated. The RHC will be prepared to mitigate damages to any individual patient, staff or visitor via continuous training and education. We will monitor, evaluate and educate our staff via the completion of at least two (02) disaster drills annually. Any time that the Emergency Operations plan is implemented a debriefing will occur with the Safety Coordinator, office coordinator, medical director and other key staff as needed to review the process and ensure that the plan functioned. If a failure occurred in the process, revisions will be made to correct the problem. This process will enable recovery and will identify actions that would mitigate the effects of future disasters as it relates to the RHC and at the individual patient level. Our goal would be to have the RHC and each patient be able to return to normal function and life as soon as possible.

Staff will be educated on Plan roles and duties during the mandatory staff education conducted by the Safety Coordinator followed by a facility-based exercise by April 6, 2018. The Safety Coordinator will be responsible for ensuring that these debriefings take place and any necessary corrections and staff reeducation occurs. Evidence of reeducation will be documented. Evaluation of staff knowledge regarding specific roles will be assessed by post-education testing completed the same date.
Monitoring and sustainment will be accomplished through periodic drills (at least twice annually) to determine staff knowledge of and ability to perform specific assigned roles and duties. Performance will be evaluated and the need for any additional education will be determined based on any identified issues. This evaluation process will be sustained annually with no end date.
Safety Coordinator is responsible for enactment of the plan.

The RHC Emergency Operations Plan is developed in conjunction with the ACMH Hospital Emergency Preparedness Plan taking into account the RHC's unique circumstances, patient population and services offered. The RHC staff plays an active role in development and sustainment of this plan. This facility is capable of actively utilizing the unified integrated emergency operation plan. Integration is achieved by the following activities:
- Participation in joint community drills with local Emergency Management agencies
- Members of the RHC actively participate in the safety program of the hospital and provide input regarding RHC emergency operations plans.
- Hospital staff provide education and assistance to the RHC in regard to Emergency Preparedness and assist with RHC specific exercises.
- The hospital and RHC plans will evidence integration of relevant processes and procedures.
The elements of the Emergency Operations Plan cited in this deficiency were specifically addressed in each plan of correction submitted.
Monitoring is achieved through the coordinated activities outlined in the plans of correction submitted. The coordination between the entities will be sustained through the continuous review and amendment of the coordinated plans, annual exercises, evaluation of staff execution of the plan, and the provision of reeducation as deemed necessary.

The Safety Coordinator is responsible for the continued implementation of this plan of correction.

All outdated items and sterile package of gauze sponges (as indicated in 0022) were removed from exam rooms and work stations and disposed of. Staff will be educated to include room deodorizers, hand sanitizers and lubricating jelly to their monthly outdate checks. Staff will be educated on proper storage of medical supplies with an emphasis on Storage of Supplies items 1 through 3. This education will ensure that outdated items are disposed of and medical supplies will be properly stored. All staff will be educated by 3/16/18 and will complete a read and sign of infection control policy 231. This read and sign signature sheet will be located in the RHC binder. The MA's are responsible to follow the policy, to check and rotate and remove the expired products weekly. This will be confirmed with the monthly inspection for outdated/expired products by the staff RN. Spot checks will be performed by the office manager monthly and recorded by initializing the monthly inspection sheet . Spot checks will also be performed by the operations manager and recorded by initializing the monthly inspection sheet. This monthly inspection sheet is located in the Inspection Binder.
Eye wash check sheet was updated to include the calendar of weekly dates to ensure that no weeks pass without a documented inspection and the eye wash station is functioning properly. Staff will be educated on the revised eye wash sheet by 3/16/18. A staff member has been assigned the responsibility for weekly eye wash inspection and documentation. The office manager will review and initial the sheet weekly for compliance for the first two months. Once compliance is achieved spot checks will be performed by the office manager and recorded on the weekly eye wash sheet. This inspection sheet is located in the inspection binder.

Staff re-education regarding hand hygiene included in the Infection Control Policy 231 will be reviewed with all staff by the practice manager and will be completed by 3/16/2018. A read and sign will be completed by all staff to indicate they read and understand Infection Control Policy 231. A copy of the signature sheet will be contained in the RHC binder. Additionally all staff completed the Net Dimensions online course on Infection Control. Verification of course completion is contained in the RHC binder. To ensure that the hand hygiene protocol is being followed, the practice manager will perform random observations of hand hygiene weekly beginning the week of 3/19/2018. The practice manager will document inspections on a log sheet for compliance or noncompliance. Noncompliance of this policy will result in discipline per ACMH protocol. If after two months the weekly inspections have found all staff to be in compliance the random checks will decrease to monthly observations.

In conjunction with the clinic medical director, physicians and APP a policy was developed to define the process for medical management and assessment of the patient and to ensure that all elements of patient medical management, assessment and care are complete. This policy is Patient Medical Management and Assessment- policy number 120 and is located in the RHC clinic policy and procedure manual. The policy language addresses the guidelines for medical management of health problems to include the reference source for medical guidelines, access to those guidelines and their relevance to management of patient order sets and templates as follows:
"POLICY: Medical Management and Patient Assessment
PURPOSE: To provide RHC practitioners with best practice guidelines and determine the process for medical management and assessment of the patients' health status based on these guidelines in addition to physician judgment and expertise for the development of the patient plan of care.
Definition:
Medical Management – is the comprehensive plan for patient assessment and management providing clinicians with practical state of the art information on the diagnoses and treatment of medical conditions.
Patient Assessment- a comprehensive review of patient history, presenting condition, medications, physical examination, and determination of the need for additional health care services
PROCEDURE:
1. Medical Management is facilitated by the following processes:
a. Development of order sets that guide medical management of health problems in accordance with best practice guidelines. When order sets are developed or reviewed, the practitioners utilize "UpToDate" – an on line, evidenced based clinical decision support that critically evaluates available medical literature, includes treatment recommendation, drug information and educational resources. UpToDate in integrated with the EMR so that practitioners can access the best practice recommendations as a guide for medical management.
b. When order sets are not utilized for medical management (example: treatment of the common cold), the EMR support team and the clinicians utilize "UpToDate" to
Develop templates to capture current conditions and treatment plans for patient care and assessment.
c. Performance of a comprehensive patient assessment
d. Development of a treatment plan
e. Determining a need for consultation and or referral
f. Identification of the need for follow-up care
g. Scheduling of the next follow-up appointment

2. Patient Assessment
The scope of assessment is determined by the patients ':
- Chief complaint
- History of present illness and family/social history
- Review of systems
- Vitals
- Physical Examination and assessment
- Current medications
- Condition and diagnosis
- Response to any previous care
- Consent to treatment
The provider will complete an assessment of the patient to include: review pertinent physical and medical history, presenting patient issues and concerns, current medications, physical exam as indicated, determination of the appropriate plan of care, the need for prescriptions for medications, orders for any follow up care or treatment and/or consult/referrals for specialty services, need for patient education and follow up visit.
3. Documentation of Medical Management and Assessment
All practitioners will be responsible for addressing the chief complaint with the patient and ensuring that that complaint is documented, updated and addressed at the visit. The process for management of the chief complaint is as follows:
a. Patients calling for appointments for a specific issue and for patient scheduling follow up or annual visits will have a chief reason/complaint logged into the note section of the Electronic Health Record (EHR) appointment screen. This chief complaint will flow electronically to the provider progress note.
b. The medical assistant will verify the reason for the patient visit and edit the chief complaint as needed. If no chief complaint is listed, the medical assistant will log the reason for the patient's visit into the electronic record.
c. The provider will review the documentation provided by the MA or nurse in the EHR.
d. The provider medical management plan will be documented in the electronic record progress note including the patient assessment, treatment plan, medications, recommendations for consultation/referral, follow-up visits and testing.
e. The provider will direct office support staff on any follow up visits or testing to be scheduled.
f. Any testing scheduled will be documented in the patients EHR."

Practitioner will be educated on policy content and responsibilities during the next RHC staff meeting scheduled on March 29, 2018. Evidence of education will be documented via read and sign of the policy.
Monitoring of the process for medical management will be accomplished by establishment of a process review team including the RHC Medical Director, Chief Medical Officer (CMO), physician, APP and the practice manager. The process review team will conduct audits of the process beginning in April (date to be coordinated with practitioners' schedules). The process review team will develop an audit tool and audit criteria that will include evaluation of the medical management process including: utilization of best practice resources, completeness of documentation addressing the patient visit, compliance with ordering and administration procedures and all follow up care and treatment. Five (05) charts will be chosen at random from the prior week's schedule. Audit deficiencies will be identified, recorded and addressed with the process review team committee, and practitioners will receive additional education as needed. When audits consistently confirm charts are properly completed without deficiency, audits will then be conducted on a monthly basis reviewing a minimum of ten (10) charts for an additional three (03) months.

In order to demonstrate evidence that the clinical records document the provision of diagnostic and therapeutic services, performance of physical examinations, conduction of the assessment of patient health status and development and implementation of treatment plans for a variety of medical conditions has been achieved; we have developed a chart audit of compliance with medical management processes.
The development of policy 120 "Medical Management and Patient Assessment" and its content demonstrates that the RHC staff have been provided with comprehensive guidelines and procedures to drive education efforts and the construct for monitoring and continued sustainment.
Practitioners will be educated on policy content and responsibilities during the next RHC staff meeting scheduled on March 29, 2018. Evidence of education will be documented via read and sign of the policy.
Monitoring of the process for medical management will be accomplished by establishment of a process review team including the RHC Medical Director, Chief Medical Officer (CMO), physician, APP and the practice manager. The process review team will conduct audits of the process beginning in April (date to be coordinated with practitioners' schedules). The process review team will develop an audit tool and audit criteria that will include evaluation of the medical management process including: utilization of best practice resources, completeness of documentation addressing the patient visit, compliance with ordering and administration procedures and all follow up care and treatment. Five (05) charts will be chosen at random from the prior week's schedule. Audit deficiencies will be identified, recorded and addressed with the process review team committee, and practitioners will receive additional education as needed. When audits consistently confirm charts are properly completed without deficiency, audits will then be conducted on a monthly basis reviewing a minimum of ten (10) charts for an additional three (3) months.

The RHC provides medical emergency procedures as a first response to common life-threatening injuries and acute illnesses, and has drugs and biologicals commonly used in life saving procedures relevant to the population of our immediate geographic region and the most commonly identified medical conditions treated by first responders. These decisions are made by the practice physicians in conjunction with local EMS professionals who periodically review the list to determine the need for any amendments. Drugs and biological may be added or excluded from this list based on the geographical region and identified need of the population.
Clinic policy 5015- Medical Emergencies has been revised and updated to include emergency medications and the quantity of each maintained in the clinic. Included in the policy and available in the clinic for emergencies are:
- 4 tabs of Aspirin
- 1 vial of Lidocaine1%
- 1 vial of Rocephin
- 1 tablet of Zofran
- 1 bottle of Nitroglycerine
- 1 vial of Benadryl
- 1 ampule of Epinephrine
- 1 vial of Ativan - located in medication refrigerator
- 1 dose (.5ml) of Tetanus/diphtheria- located in medication refrigerator

Education will be provided to all staff will complete a read and sign of the medical emergencies policy by 3/16/18.
It is the responsibility of the office nurse to ensure that the medication is present in the clinic in the quantities required and continue to perform monthly medication inspections. The operations manager will perform random checks utilizing the emergency medication checklist to verify that medications are present in the quantities specified according to policy.

In conjunction with the clinic medical director, physicians and APP a policy was developed for patient assessment to ensure patient health care records are complete. This policy ensures all providers orders, reports of treatment and medications and other pertinent information necessary to monitor the patient's progress has been identified and documented. This policy is Patient Assessment- policy number 120 and is located in the clinic policy and procedure manual.
The clinic will utilize the Clinical Record Audit form for periodic audits of patient records. Audits will be conducted by the Medical Director of the RHC, Chief Medical Director, physician and APP and the practice manager (quality improvement team). These audits will be conducted bi-weekly beginning 3/26/18 to review 5 charts per provider chosen at random from the prior weeks schedule. When audits confirm charts are properly completed, audits will be conducted on a monthly basis by the quality improvement team. . When progression is made to monthly audits 10 charts per provider will be chosen at random for review from the prior months schedule. All completed chart audit forms will be housed in the RHC binder.

Deficiencies will be recorded and addressed during the QI meeting. Re-education of deficiencies identified will ensure that providers are aware of importance of completeness of patient medical record in accordance with policy number 120.
The chart reviews will be located in the RHC binder.

On 3/2/2018 the tickler files were removed from the portable plastic file box. The files were placed in a permanent locking file cabinet within the reception area by the practice manager. The keys to the cabinet are secured by the receptionist and practice manager. The receptionist is responsible for ensuring the cabinet is locked at all times when not in use. This will ensure that these patient files are kept confidential and secure.
To ensure ongoing compliance a closing check list will be instituted by the practice manager and completed daily by an assigned staff member to ensure confidential information is secured at close of business. Practice manager will monitor this sheet daily. Staff will be educated by 3/16/18 on the end of day process. Education sheet with staff signatures confirming education will be located in RHC binder.