1. Joint Commission Accreditation_Reports.pdf

Final Accreditation Report

George E. Wahlen VA Salt Lake City Health Care System 500 Foothill Boulevard

Salt Lake City, UT 84148

Organization Identification Number: 9545 Unannounced Full Event: 2/5/2019 - 2/8/2019

Programs Surveyed

Hospital Behavioral Health

Home Care

Final Report: Posted 2/14/2019

Table of Contents

Executive Summary 3 What’s Next - Follow-up Activity 4 Hospital 9

• SAFER™ Matrix 9

• Requirements for Improvement (RFI) 11

Behavioral Health 23

• SAFER™ Matrix 23

• Requirements for Improvement (RFI) 24

Home Care 26

• SAFER™ Matrix 26

• Requirements for Improvement (RFI) 27

Appendix 31

• Standards/Elements of Performance (EP) Language 31

• Report Section Descriptions 42

• Clarification Instructions 44

The Joint Commission

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Executive Summary

Program Survey Dates Event Outcome Follow-up Activity Follow-up Time Frame or Submission Due Date

Hospital 02/05/2019 - 02/08/2019

Requirements for Improvement

Clarification (Optional) Submit within 10 Business Days from the final posted report date

Evidence of Standards Compliance (ESC)

Submit within 60 Calendar Days from the final posted report date

Behavioral Health

02/05/2019 - 02/07/2019

Requirements for Improvement

Clarification (Optional) Submit within 10 Business Days from the final posted report date

Evidence of Standards Compliance (ESC)

Submit within 60 Calendar Days from the final posted report date

Home Care 02/05/2019 - 02/08/2019

Requirements for Improvement

Clarification (Optional) Submit within 10 Business Days from the final posted report date

Evidence of Standards Compliance (ESC)

Submit within 60 Calendar Days from the final posted report date

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Program: Hospital

What’s Next - Follow-up Activity

Included in the Evidence of Standard Compliance (within 60 calendar days)

EC.02.02.01 5 Moderate / Limited

EC.02.03.01 12 Moderate / Widespread

13 Low / Limited

EC.02.04.03 2 Moderate / Widespread

3 Low / Pattern

EC.02.05.01 15 Moderate / Widespread

16 Low / Limited

EC.02.05.05 6 Low / Limited

EC.02.05.07 4 Low / Widespread

EC.02.05.09 12 Low / Limited

5 Low / Limited

6 Low / Limited

EC.02.06.01 1 Moderate / Pattern

20 Low / Pattern

26 Moderate / Widespread

HR.01.05.03 15 Moderate / Pattern

Standard EP SAFER™ Placement

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Included in the Evidence of Standard Compliance (within 60 calendar days)

IC.02.01.01 1 Low / Limited

2 Low / Limited

IC.02.02.01 1 Low / Limited

2 High / Pattern

4 Low / Pattern

LD.03.09.01 7 Low / Limited

LD.04.01.01 2 Low / Widespread

LS.02.01.20 1 Low / Pattern

13 Low / Limited

LS.02.01.30 2 Low / Pattern

20 Low / Limited

3 Low / Pattern

LS.02.01.35 14 Low / Pattern

6 Low / Limited

7 Low / Pattern

LS.02.01.70 6 Low / Limited

MM.03.01.01 6 Low / Limited

NPSG.15.01.0

2 Moderate / Limited

PC.01.02.08 1 Low / Limited

Standard EP SAFER™ Placement

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Included in the Evidence of Standard Compliance (within 60 calendar days)

PC.02.01.11 2 Moderate / Limited

PC.03.01.03 1 Moderate / Limited

8 Low / Pattern

PC.03.05.03 2 Low / Widespread

PC.04.01.05 7 Moderate / Limited

TS.03.02.01 5 Low / Widespread

UP.01.03.01 2 Moderate / Limited

Standard EP SAFER™ Placement

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Program: Behavioral Health

Included in the Evidence of Standard Compliance (within 60 calendar days)

CTS.02.01.11 1 Low / Pattern

CTS.02.02.01 1 Low / Limited

CTS.02.02.05 2 Low / Limited

CTS.04.03.33 3 Low / Limited

EC.02.06.01 20 Low / Pattern

Standard EP SAFER™ Placement

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Program: Home Care

Included in the Evidence of Standard Compliance (within 60 calendar days)

EQ.01.03.01 7 Low / Limited

LD.04.01.05 5 High / Widespread

LD.04.01.07 1 High / Widespread

NPSG.15.02.0

2 Moderate / Widespread

PC.01.02.03 1 Moderate / Pattern

PC.02.03.01 4 Low / Limited

PI.01.01.01 15 Low / Widespread

RC.02.01.01 2 Moderate / Pattern

Standard EP SAFER™ Placement

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Li ke lih oo d to h ar m a

P at ie nt

Vi si to r / S ta ff

Program: Hospital

SAFER™ Matrix

ITL

High

IC.02.02.01 EP 2

Moderate

EC.02.02.01 EP 5

NPSG.15.01.01 EP 2

PC.02.01.11 EP 2

PC.03.01.03 EP 1

PC.04.01.05 EP 7

UP.01.03.01 EP 2

EC.02.06.01 EP 1

HR.01.05.03 EP 15

EC.02.03.01 EP 12

EC.02.04.03 EP 2

EC.02.05.01 EP 15

EC.02.06.01 EP 26

Low

EC.02.03.01 EP 13

EC.02.05.01 EP 16

EC.02.05.05 EP 6

EC.02.05.09 EP 5

EC.02.05.09 EP 6

EC.02.05.09 EP 12

IC.02.01.01 EP 1

IC.02.01.01 EP 2

IC.02.02.01 EP 1

LD.03.09.01 EP 7

LS.02.01.20 EP 13

LS.02.01.30 EP 20

LS.02.01.35 EP 6

LS.02.01.70 EP 6

MM.03.01.01 EP 6

PC.01.02.08 EP 1

EC.02.04.03 EP 3

EC.02.06.01 EP 20

IC.02.02.01 EP 4

LS.02.01.20 EP 1

LS.02.01.30 EP 2

LS.02.01.30 EP 3

LS.02.01.35 EP 7

LS.02.01.35 EP 14

PC.03.01.03 EP 8

EC.02.05.07 EP 4

LD.04.01.01 EP 2

PC.03.05.03 EP 2

TS.03.02.01 EP 5

Limited Pattern Widespread

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Scope

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Requirements for Improvement

Standard EP SAFER™ Placement EP Text Observation

EC.02.02.01 5 Moderate Limited

The hospital minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous chemicals.

1). Observed in Individual Tracer at Western Salt Lake VA Community Based Outpatient Clinic (2750 South 5600 West, West Valley, UT) site . ThinPrep PreserveCyt Solution is used in the Western Salt Lake Community Based Outreach Clinic to preserve specimens in the PAP/Pelvic Exam Process. The safety data sheet and organization policy entitled Pap/Pelvic Exam Process requires goggle eye protection.. Staff interview reveals that staff is not using goggle eye protection.

EC.02.03.01 12 Moderate Widespread

When flammable germicides or antiseptics are used during surgeries utilizing electrosurgery, cautery, or lasers, the following are required:

- Nonflammable packaging

- Unit-dose applicators

- Preoperative "time-out" prior to the initiation of any surgical procedure to verify the following:

- Application site is dry prior to draping and use of surgical equipment

- Pooling of solution has not occurred or has been corrected

- Solution-soaked materials have been removed from the operating room prior to draping and use of surgical devices (For full text, refer to NFPA 99-2012: 15.13)

1). Observed in Tracer Activities at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . In a patient that had been prepped with Chloraprep, there was no procedure in place to verify that the site was dry, that there was no pooling and that solution-soaked materials had been removed prior to draping the patient. These procedures are necessary to help manage the risk for fire.

EC.02.03.01 13 Low Limited

The hospital meets all other Health Care Facilities Code fire protection requirements, as related to NFPA 99-2012: Chapter 15.

1). Observed in Building Tour at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . The organization did not meet the provisions of the NFPA 101-2018 Edition of the Life Safety Code. There was a 1/8th inch gap in the ceiling tile in the Central Decontamination area men’s locker room. There was a smoke detector in the room of this business occupancy.

EC.02.04.03 2 Moderate Widespread

The hospital inspects, tests, and maintains all high-risk equipment.

These activities are documented. (See also PC.02.01.11, EP 2) Note 1: High-risk equipment includes medical equipment for which there is a risk of serious injury or even death to a patient or staff member should it fail, which includes life-support equipment.

Note 2: Required activities and associated frequencies for maintaining, inspecting, and testing of medical equipment completed in accordance with manufacturers’ recommendations must have a 100% completion rate.

1). Observed in Tracer Activities at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . The hospital was not maintaining the Medivator Advantage Plus automated reprocessors as required by the manufacturer's instructions for use (IFU). For example, a 0.1 micron water filter was changed on 2/6/17 and not again until 9/28/18. The manufacturer's IFU states that the filter should be changed every 6 months. There was no documentation that the waterline was disinfected after the filter change. The 0.1 micron

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Standard EP SAFER™ Placement EP Text Observation

Note 3: Scheduled maintenance activities for high-risk medical equipment in an alternative equipment maintenance (AEM) program inventory must have a 100% completion rate. AEM frequency is determined by the hospital's AEM program.

filters were last changed in August and September 2018, the survey was conducted in February 2019 and the IFU states that the filter should be changed every 3 months. There was no documentation of when the last time was that the air filters had been changed. This was confirmed with the Associate Chief of Staff.

EC.02.04.03 3 Low Pattern

The hospital inspects, tests, and maintains non-high-risk equipment identified on the medical equipment inventory. These activities are documented.

Note: Scheduled maintenance activities for non-high-risk medical equipment in an alternative equipment maintenance (AEM) program inventory must have a 100% completion rate. AEM frequency is determined by the hospital’s AEM program.

1). Observed in Tracer Visit at Ogden VA Community Based Outpatient Clinic, South Ogden UT (982 Chambers Street, South Ogden, UT) site . An imaging device used to take retinal images had an equipment maintenance sticker indicating that the due date for PM would not occur until this piece of medical equipment was in need of repair. The manufacturer instructions for this instrument indicated that annual maintenance is needed. Staff stated that the practice of the organization was to place stickers indicating "no PM until repair is required" on all equipment serviced by a vendor.

There was no vendor sticker on this device, and there were no records of vendor annual preventative maintenance.

EC.02.05.01 15 Moderate Widespread

In critical care areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, filtration efficiencies, temperature and humidity.

Note: For more information about areas designed for control of airborne contaminants, the basis for design compliance is the Guidelines for Design and Construction of Health Care Facilities, based on the edition used at the time of design (if available).

1). Observed in Building Tour at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . The Operating Rooms #1 through 6 had temperatures below the requirements of the ASHRAE 170 on the day of the survey..

2). Observed in Building Tour at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . The door to the OR #5 leading to the sub-sterile core was negative to the sub-sterile core.

EC.02.05.01 16 Low Limited

In non–critical care areas, the ventilation system provides required pressure relationships, temperature, and humidity.

Note: Examples of non–critical care areas are general care nursing units; clean and soiled utility rooms in acute care areas;

laboratories, pharmacies, diagnostic and treatment areas, food preparation areas, and other support departments.

1). Observed in Building Tour at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . The door leading to the clean supply room in the Logistics area was negative to the surrounding hallway.

EC.02.05.05 6 Low Limited

The hospital inspects, tests, and maintains the following: Non-high-risk utility system components on the inventory. The completion date and the results of the activities are documented.

Note: Scheduled maintenance activities for non-high-risk utility systems components in an alternative equipment maintenance

1). Observed in Building Tour at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . The electrical panel in the OR#2 Electrical room was blocked with supplies.

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(AEM) program inventory must have a 100% completion rate. AEM frequency is determined by the hospital AEM program.

EC.02.05.07 4 Low Widespread

Every week, the hospital inspects the emergency power supply system (EPSS), including all associated components and batteries.

The results and completion dates of the inspections are documented. (For full text, refer to NFPA 110-2010: 8.3.1; 8.3.3;

8.3.4; 8.4.1)

1). Observed in Document Review at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . There was no documentation the organization tested the generator batteries monthly as required by the NFPA 110-2016 Edition, Section 8.3.6.1.

EC.02.05.09 5 Low Limited

A precautionary sign readable from 5 feet away is on each door or gate of a cylinder storage room, where the sign, at a minimum, includes the wording "CAUTION: OXIDIZING GAS(ES) STORED WITHIN. NO SMOKING.” Storage is planned so cylinders are used in the order they are received from the supplier. Only gas cylinders and reusable shipping containers and their accessories are permitted to be stored in rooms containing central supply systems or gas cylinders.

1). Observed in Building Tour at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . The door to the medical gas room did not have the appropriate signage as required by the NFPA 99-2015 Edition.

EC.02.05.09 6 Low Limited

When the hospital uses cylinders with an integral pressure gauge, a threshold pressure considered empty is established when the volume of stored gases is as follows:

- When more than 300 but less than 3,000 cubic feet, the storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited-combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2-hour fire protection rating.

- When less than 301 cubic feet in a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in NFPA 99-2012: 11.6.2.

(For full text, refer to NFPA 99-2012: 5.1.3.1; 5.1.3.2.3; 5.2.3.1;

5.3.10; 11.3; 11.6.5.2.1)

1). Observed in Building Tour at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . There were empty and full oxygen cylinders stored in the same rack in the medical gas room in the OR.

EC.02.05.09 12 Low Limited

The hospital implements a policy on all cylinders within the hospital that includes the following:

- Labeling, handling, and transporting (for example, in carts, attached to equipment, on racks) in accordance with NFPA 99- 2012: 11.5.3.1 and 11.6.2

- Physically segregating full and empty cylinders from each other in order to assist staff in selecting the proper cylinder

1). Observed in Tracer Activities at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . During tracer activities in the Telemetry Unit, there was one unsecured oxygen tank located in the nurse's station. The tank was moved into the correct storage rack immediately during survey by the Unit Manager.

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- Adaptors or conversion fittings are prohibited

- Oxygen cylinders, containers, and associated equipment are protected from contamination, damage, and contact with oil and grease

- Cylinders are kept away from heat and flammable materials and do not exceed a temperature of 130°F

- Nitrous oxide and carbon dioxide cylinders do not reach temperatures lower than manufacturer recommendations or -20°F

- Valve protection caps (if supplied) are secured in place when cylinder is not in use

- Labeling empty cylinders

- Prohibiting transfilling in any compartment with patient care (For full text, refer to NFPA 99-2012: 11.6.1; 11.6.2; 11.6.5; 11.7.3)

EC.02.06.01 1 Moderate Pattern

Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided.

1). Observed in Tracer Activities at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . During tracer activities in the PT/OT Department, there were five stained ceiling tiles and one water stained light located in the hallway where the hydrocollator, hot pack pads and other patient care items were stored. The Outpatient PT Supervisor verified this observation.

2). Observed in Tracer Activities at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . In tracer activity in the Emergency Department, the restraint rings on the patient bed and the non-ligature resistant door handles inside and outside Room 2 designated as the safe room were not identified on the Departmental Risk Assessment.

3). Observed in Tracer Activities at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . There were multiple areas in endoscopy room 2 and the endoscopy central core where the drywall had been patched but not painted. This was confirmed with the unit manager.

EC.02.06.01 20 Low Pattern

Areas used by patients are clean and free of offensive odors. 1). Observed in Tracer Activities at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . During tracer activities in the PT/OT Department, there was a significant amount of dust and debris present on the low, horizontal surfaces of multiple pieces of exercise equipment. The Outpatient PT Supervisor verified this observation.

EC.02.06.01 26 Moderate Widespread

The hospital keeps furnishings and equipment safe and in good repair.

1). Observed in Tracer Activities at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . During tracer activities in the PT/OT Department, the

14 of 44Organization Identification Number: 9545 Final Report: Posted 2/14/2019 therapy stairs were observed to have the non-skid tread rolled up and frayed that created a potential trip hazard for patients. The Outpatient PT Supervisor verified this observation.

2). Observed in Tracer Activities at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . During tracer activities in the PT/OT Department, the hydrocollator temperature monitoring log had two days in January 2019 that no temperature was taken. This was not in accordance with the PM&R Policy 117.PMR.100.HP (January 2016) titled "Chattanooga Hydrocollator Heating Unit". The Outpatient PT Supervisor verified this observation.

3). Observed in Tracer Activities at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . During tracer activities in the PT/OT Department, there was no evidence of temperature monitoring for the paraffin unit.

According to the manufacturer's instructions for use, the temperature was to be tested by thermometer to remain within a range of 126 - 134 degrees Fahrenheit. The Occupational Therapy Supervisor verified this observation.

HR.01.05.03 15 Moderate Pattern

The hospital verifies and documents that individuals (including physicians, non-physicians, and ancillary personnel) who use fluoroscopic equipment participate in ongoing education that includes annual training on the following:

- Radiation dose optimization techniques and tools for pediatric and adult patients addressed in the Image Gently® campaign

- Safe procedures for operation of the types of fluoroscopy equipment they will use Note 1: Information on the Image Gently initiative can be found online at http://www.imagegently.org.

Note 2: This element of performance does not apply to fluoroscopy equipment used for therapeutic radiation treatment planning or delivery.

1). Observed in Credentialing and Privileging at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . The organization was not able to provide evidence that an orthopedic fellow and speech pathologist had received radiation safety training as required by VHA Directive

1105.04 June 21, 2018. This was confirmed with the radiology

director.

IC.02.01.01 1 Low Limited

The hospital implements its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection. (See also MM.09.01.01, EP 5)

1). Observed in Tracer Visit at Western Salt Lake VA Community Based Outpatient Clinic (2750 South 5600 West, West Valley, UT) site . A linen cart with a wire rack bottom, and no solid bottom protection, was observed in the supply room. This was corrected during the survey by placing a solid protector on the bottom rack.

IC.02.01.01 2 Low Limited

The hospital uses standard precautions, * including the use of personal protective equipment, to reduce the risk of infection. (See also EC.02.02.01, EP 4)

1). Observed in Tracer Activities at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . In tracer activity in the Inpatient Behavioral Health unit, 15 of 44Organization Identification Number: 9545 Final Report: Posted 2/14/2019

Note: Standard precautions are infection prevention and control measures to protect against possible exposure to infectious agents. These precautions are general and applicable to all patients.

Footnote *: For further information regarding standard precautions, refer to the website of the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/hai/ (Infection Control in Healthcare Settings).

two patient care staff had artificial fingernails, which are prohibited by organization policy "Hand Hygiene" dated September 2015, page 4, 6.d.5. Artificial nails...are not to be worn by personnel providing direct patient care.

IC.02.02.01 1 Low Limited

The hospital implements infection prevention and control activities when doing the following: Cleaning and performing low-level disinfection of medical equipment, devices, and supplies. * Note: Low-level disinfection is used for items such as stethoscopes and blood glucose meters. Additional cleaning and disinfecting is required for medical equipment, devices, and supplies used by patients who are isolated as part of implementing transmission-based precautions.

Footnote *: For further information regarding cleaning and performing low-level disinfection of medical equipment, devices, and supplies, refer to the website of the Centers for Disease Control and Prevention (CDC) at https://www.cdc.gov/infectioncontrol/guidelines/disinfection/#r3.

1). Observed in Tracer Activities at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . During tracer activities in the PT/OT Department, the paraffin unit was observed to have brown dirt and debris present in the paraffin. According to the manufacturer's instructions for use, the Parabath Unit Bath should be cleaned when significant discoloration or yellowing of the paraffin is noticed, or when excessive sediment is observed in the tank". The Occupational Therapy Supervisor verified this observation. The paraffin unit was drained and cleaned during the survey.

IC.02.02.01 2 High Pattern

The hospital implements infection prevention and control activities when doing the following: Performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies. * (See also EC.02.04.03, EP 4) Note: Sterilization is used for items such as implants and surgical instruments. High-level disinfection may also be used if sterilization is not possible, as is the case with flexible endoscopes.

Footnote *: For further information regarding performing intermediate and high-level disinfection of medical equipment, devices, and supplies, refer to the website of the Centers for Disease Control and Prevention (CDC) at https://www.cdc.gov/infectioncontrol/guidelines/disinfection/#r3 (Sterilization and Disinfection in Healthcare Settings).

1). Observed in Tracer Activities at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . During individual tracer activity in central sterile processing, two sharp towel clips had been packaged and were on the rack awaiting sterilization and were noted to be ratcheted shut. There were also 3 of 5 pairs of scissors that were noted to be in the closed position as they came out of the automated instrument washer. The hospital follows AAMI guidelines and it was confirmed with the OR director that these instruments should have been in the open position.

2). Observed in Tracer Activities at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . When using CidexOPA the organization was not monitoring the temperature of the solution during decontamination of the Scope Buddy. In addition, they were only performing one set of testing of the test strips rather than the 3 sets of positive and negative tests as required by the manufacturer's instructions for

16 of 44Organization Identification Number: 9545 Final Report: Posted 2/14/2019 use. This was confirmed with the director of central sterile processing.

3). Observed in Tracer Activities at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . During observation of decontamination of a colonoscope in the 4th floor endoscopy processing area, a detergent rather than a disinfectant was being used to perform the daily disinfection of the Scope Buddy. The manufacturer's instructions for use state to use a disinfectant. This was confirmed with the Chief of Sterile Processing Service.

IC.02.02.01 4 Low Pattern

The hospital implements infection prevention and control activities when doing the following: Storing medical equipment, devices, and supplies.

1). Observed in Tracer Visit at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . During individual tracer activity in the anesthesia work room, the ultrasound gel bottles that were open for use on the ultrasound machines were not dated with a new 30 day expiration date after opening as per the manufacturer's instructions for use. This was confirmed with the OR director.

LD.03.09.01 7 Low Limited

At least every 18 months, the hospital selects one high-risk process and conducts a proactive risk assessment. (See also

LD.03.08.01, EP 1)

Note: For suggested components, refer to the "Proactive Risk Assessment" section at the beginning of this chapter.

1). Observed in Data Tracer at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . During review of the organization's data, there was no evidence of a proactive risk assessment having been completed in the last 18 months. The most recent HFMEA had been completed in May 2017. The Director of Quality verified this observation.

LD.04.01.01 2 Low Widespread

The hospital provides care, treatment, and services in accordance with licensure requirements, laws, and rules and regulations.

Note: For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital meets the Centers for Medicare & Medicaid Services’ (CMS) definition of a hospital in accordance with 42 CFR 482.1(a)(1) and (b). (See Appendix A [AXA] for the language of this CMS requirement.)

1). Observed in Tracer Activities at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . In tracer activity in the Emergency Department, the electronic charting system prepopulates a Vaccine Information Statement (VIS) edition date of 5/9/13 following the Tdap vaccine selection. The actual VIS edition date given is the most recent version dated 2/24/2015.

LS.02.01.20 1 Low Pattern

Doors in a means of egress are not equipped with a latch or lock that requires the use of a tool or key from the egress side, unless a compliant locking configuration is used, such as a delayed-egress locking system as defined in NFPA 101-2012: 7.2.1.6.1 or access-controlled egress door assemblies as defined in NFPA 101-2012:

7.2.1.6.2. Elevator lobby exit access door locking is allowed if compliant with 7.2.1.6.3. (For full text, refer to NFPA 101-2012:

18/19.2.2.2.4; 18/19.2.2.2.5; 18/19.2.2.2.6) Note: For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital meets the applicable

1). Observed in Building Tour at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . During a tour of a ER, an exit door had a delayed-egress device installed; however, the required sign was not present on the door for the delay.

The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization’s ILSM policy: Increase surveillance (EP-8), Train staff on fire safety features(EP-14)

17 of 44Organization Identification Number: 9545 Final Report: Posted 2/14/2019 provisions of the Life Safety Code Tentative Interim Amendment

(TIA) 12-4.

LS.02.01.20 13 Low Limited

An exit enclosure is not used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. Open space within the exit enclosure is not used for any purpose that has the potential to interfere with egress. (For full text, refer to NFPA 101-2012: 18/19.2.2.3; 7.1.3.2.3; 7.2.2.5.3.1)

1). Observed in Building Tour at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . There were 2 wet floor signs in the exit stair #Building #1 in Stairwell # 2CA-1. This finding was observed during survey activity, but corrected onsite prior to the surveyor’s departure. The corrective action taken needs to be included in the organization’s Evidence of Standards Compliance submission

LS.02.01.30 2 Low Pattern

All new hazardous areas have doors that are self-closing or automatic-closing, except for laboratories using flammable or combustible materials deemed less than a severe hazard and storage rooms greater than 50 square feet, but less than 100 square feet that are used for storage of combustible material.

Hazardous areas have a fire barrier with a one-hour fire-resistive rating. These areas include, but are not limited to, boiler and fuel-fired heater rooms, central/bulk laundries larger than 100 square feet, paint shops, repair shops, soiled linen rooms, trash collection rooms with containers exceeding 64 gallons, laboratories considered a severe hazard, and storage rooms larger than 100 square feet that contain combustible material. (For full text, refer to NFPA 101-2012: 18.3.2.1; 18.3.2.2; 18.3.2.3; 18.3.2.4; Table 18.3.2.1) Note: For hospitals that use Joint Commission accreditation for deemed status purposes: Doors to rooms containing flammable or combustible materials are provided with positive latching hardware.

Roller latches are prohibited on such doors.

1). Observed in Building Tour at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . In 4 of 10 Hazard room checks, 1) the room next to OR 2 was converted to a new storage room of combustible supplies did not have the required 1 hour walls and 45 minute fire rated door as required by the NFPA 101-2018 Edition of the Life Safety Code. 2) the anesthesia work room in the OR was converted to a new storage room of combustible supplies did not have the required 1 hour walls and 45 minute fire rated door as required by the NFPA 101-2018 Edition of the Life Safety Code. 3) the door to the Equipment Storage room #3B34 was mechanically held open. 4) the door to the Equipment Storage room #3B28 was mechanically held openThe surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization’s ILSM policy: Increase surveillance (EP-8), Train staff on fire safety features(EP-14)

LS.02.01.30 3 Low Pattern

All existing hazardous areas have doors that are self-closing or automatic-closing. These areas are protected by either a fire barrier with one-hour fire-resistive rating or an approved electrically supervised automatic sprinkler system. Hazardous areas include, but are not limited to, boiler and fuel-fired heater rooms, central/bulk laundries larger than 100 square feet, paint shops, repair shops, soiled linen rooms, trash collection rooms with containers exceeding 64 gallons, laboratories employing flammable or combustible materials deemed less than a severe hazard, and storage rooms greater than 50 square feet used for storage of equipment and combustible supplies. (For full text, refer to NFPA 101-2012: 19.3.2.1; 19.3.2.2; 19.3.2.3; 19.3.2.4) Note: For hospitals that use Joint Commission accreditation for deemed status purposes: Doors to rooms containing flammable or

1). Observed in Building Tour at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . The storage room in the Central Core designated as a hazard room on the Life Safety Drawings did not properly latch when tested.This finding was observed during survey activity, but corrected onsite prior to the surveyor’s departure. The corrective action taken needs to be included in the organization’s Evidence of Standards Compliance submission

18 of 44Organization Identification Number: 9545 Final Report: Posted 2/14/2019 combustible materials are provided with positive latching hardware.

Roller latches are prohibited on such doors.

2). Observed in Building Tour at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . There was no self-closing or automatic-closing device on the door to the Emergency Room storage room. The room was larger than 100 square feet and contained combustible patient supplies. This finding was observed during survey activity, but corrected onsite prior to the surveyor’s departure. The corrective action taken needs to be included in the organization’s Evidence of Standards Compliance submission 3). Observed in Building Tour at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . The 90 minute fire rated door to the linen chute room was modified. The door had been fitted with a piano hinge where the old hinge cuts had holes in the door.The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization’s ILSM policy:

Increase surveillance(EP-8), Train staff on fire safety features(EP- 14) 4). Observed in Building Tour at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . The door to the ICU equipment storage room #3D31 did not properly latch when tested.This finding was observed during survey activity, but corrected onsite prior to the surveyor’s departure. The corrective action taken needs to be included in the organization’s Evidence of Standards Compliance submission

LS.02.01.30 20 Low Limited

Doors in smoke barriers are self-closing or automatic-closing, constructed of 1 3/4-inch or thicker solid bonded wood core or constructed to resist fire for not less than 20 minutes, and fitted to resist the passage of smoke. The gap between meeting edges of door pairs is no wider than 1/8 of an inch. In new buildings, undercuts are no larger than 3/4 of an inch, and doors in a means of egress swing in the opposite direction. (For full text, refer to

NFPA 101-2012: 18.3.7.6; 18/19.3.7.8; 8.5.4.1; NFPA 80-2010:

4.8.4.1; 6.3.1.7.1)

1). Observed in Building Tour at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . The smoke door in the smoke barrier to the back door of ER leading to primary care had a gap larger than 1/8 inch.The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization’s ILSM policy: Increase surveillance(EP-8), Train staff on fire safety features(EP-14)

LS.02.01.35 6 Low Limited

There are 18 inches or more of open space maintained below the sprinkler deflector to the top of storage.

Note: Perimeter wall and stack shelving may extend up to the

1). Observed in Building Tour at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . There was a stationary multi-tiered storage rack in the

19 of 44Organization Identification Number: 9545 Final Report: Posted 2/14/2019 ceiling when not located directly below a sprinkler head. (For full text, refer to NFPA 101-2012: 18.3.5.1; 19.3.5.3; 9.7.1.1; NFPA 13- 2010: 8.5.5.2; 8.5.5.2.1; 8.5.5.3)

Main Core of the OR that had the top shelf less than 18 inches from the 2 sprinkler deflector in the room.The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization’s ILSM policy: Increase surveillance(EP-8), Train staff on fire safety features(EP-14) 2). Observed in Tracer Activities at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . In tracer activity in the Inpatient Behavioral Health unit, a supply shelving cart had supplies on the top most shelf that were less than 18 inches of space from the sprinkler deflector. The cart was moved prior to the surveyor leaving the unit.This finding was observed during survey activity, but corrected onsite prior to the surveyor’s departure. The corrective action taken needs to be included in the organization’s Evidence of Standards Compliance submission

LS.02.01.35 7 Low Pattern

At least six spare sprinkler heads, with associated wrenches, are kept in a cabinet that will not exceed 100°F. (For full text, refer to

NFPA 101-2012: 18.3.5.1; 19.3.5.3; 9.7.1.1; NFPA 25-2011:

5.4.1.4; 5.4.1.6; NFPA 13-2010: 6.2.9; 6.2.9.1; 6.2.9.3; 6.2.9.6)

1). Observed in Building Tour at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . There was no documentation the spare fire sprinkler heads located in the Fire Pump Room Building #1 did not exceed 100 degrees Fahrenheit.This finding was observed during survey activity, but corrected onsite prior to the surveyor’s departure. The corrective action taken needs to be included in the organization’s Evidence of Standards Compliance submission

LS.02.01.35 14 Low Pattern

The hospital meets all other Life Safety Code automatic extinguishing requirements related to NFPA 101-2012: 18/19.3.5.

1). Observed in Building Tour at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . In 2 of 6 above ceiling checks, 1) there was a gap in the ceiling larger than 1/8 of an inch around the escutcheon plate in OR #2 electrical room. 2) there were 7 conduit penetrations in the ceiling tile of the OR #2 electrical room not properly sealed.This finding was observed during survey activity, but corrected onsite prior to the surveyor’s departure. The corrective action taken needs to be included in the organization’s Evidence of Standards Compliance submission

LS.02.01.70 6 Low Limited

Soiled linen and trash receptacles larger than 32 gallons are stored in a room protected as a hazardous area. (For full text, refer to

NFPA 101-2012: 18/19.7.5.7)

Note: Containers that are 96 gallons or less and are labeled and listed as meeting the requirements of FM Approval Standard 6921

1). Observed in Building Tour at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . There was a pharmacy trash collection container and a soiled linen hamper stored in patient room #3A19 that collectively were greater than 32 gallons. The area was not designated as

20 of 44Organization Identification Number: 9545 Final Report: Posted 2/14/2019

(or equivalent) and are used solely for recycling clean waste (including patient records awaiting destruction) are permitted in an unprotected area. Those containers that are greater than 96 gallons are stored in a hazardous storage area.

"hazardous area."This finding was observed during survey activity, but corrected onsite prior to the surveyor’s departure. The corrective action taken needs to be included in the organization’s Evidence of Standards Compliance submission

MM.03.01.01 6 Low Limited

The hospital prevents unauthorized individuals from obtaining medications in accordance with its policy and law and regulation.

Note: This element of performance is also applicable to sample medications.

1). Observed in Tracer Activities at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . In tracer activity in the Ambulatory Unit, a cart with code lock and knob lock containing heparin flushes was unlocked in a patient room with two patients and families present. The organization's policy states these flushes are considered medications.

NPSG.15.01.01 2 Moderate Limited

Address the patient’s immediate safety needs and most appropriate setting for treatment.

1). Observed in Record Review at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . In chart review of an Emergency Department patient identified as actively suicidal there was no evidence of the continuous observation flowsheet with every fifteen minute checks.

PC.01.02.08 1 Low Limited

The hospital assesses the patient’s risk for falls based on the patient population and setting.

1). Observed in Tracer Activities at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . While tracing a patient with a gangrenous wound on his lower extremity, it was identified that no falls assessment was conducted on the initial visit or on subsequent treatment visits.

Memorandum OOQ.21 entitled Fall Prevention and Management dated Jan 3, 2019 under section 4 Responsibilities, item g stated "The Interdisciplinary Team is responsible for assessing, treating and implementing strategies for the prevention and management of falls in their respective clinical settings."

PC.02.01.11 2 Moderate Limited

Resuscitation equipment is available for use based on the needs of the population served.

Note: For example, if the hospital has a pediatric population, pediatric resuscitation equipment should be available. (See also

EC.02.04.03, EP 2)

1). Observed in Tracer Visit at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . While surveying the Specialty Clinic area, inspection of the crash cart log identified that it was incomplete. Specifically, the cart lock number had not been documented as required. Instead of the lock number, the crash cart number had been documented 5 of the 7 days in February (closed weekends). Review of crash cart logs from January found that 5 of 5 had been completed correctly.

The finding was confirmed by the Manager of Specialty Care.

PC.03.01.03 1 Moderate Limited

Before operative or other high-risk procedures are initiated, or before moderate or deep sedation or anesthesia is administered:

The hospital conducts a presedation or preanesthesia patient assessment. (See also RC.02.01.01, EP 2)

1). Observed in Tracer Activities at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . There was no evidence that a presedation evaluation had been performed prior to a colonoscopy as the documentation of the assessment was observed to be blank at the start of the

21 of 44Organization Identification Number: 9545 Final Report: Posted 2/14/2019 procedure. This was confirmed with the unit manager.

PC.03.01.03 8 Low

Pattern The hospital reevaluates the patient immediately before administering moderate or deep sedation or anesthesia. (See also

RC.02.01.01, EP 2)

1). Observed in Tracer Activities at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . In 2 out of 2 cardiac catheterization patient records reviewed, there was no evidence of documentation that the patient was re-evaluated immediately prior to induction of moderate sedation. This was not in accordance with Memorandum 112A.03 Moderate Sedation by Non-Anesthesia Providers (June 20, 2017).

PC.03.05.03 2 Low Widespread

The use of restraint and seclusion is in accordance with a written modification to the patient's plan of care.

1). Observed in Record Review at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . In closed record review of non-violent restraint charts, the plan of care was not modified to reflect the use or discontinuation of restraints.

PC.04.01.05 7 Moderate Limited

The hospital educates the patient, and also the patient's family when it is involved in decision making or ongoing care, about how to obtain any continuing care, treatment, and services that the patient will need.

1). Observed in Tracer Visit at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . The discharge instructions for a patient being discharged did not contain any education regarding care and precautions about having just undergone general anesthesia for their procedure.

TS.03.02.01 5 Low Widespread

The hospital retains tissue records on storage temperatures, outdated procedures, manuals, and publications for a minimum of 10 years. If required by state and/or federal laws, hospitals may have to retain tissue records longer than 10 years. (See also TS.03.01.01, EPs 2 and 8)

1). Observed in Tracer Visit at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . Prior to implementing the UDI tracker system, the organization was not retaining tissue records on storage temperatures, outdated procedures, manuals, and publications for 10 years. This was confirmed with the OR director.

UP.01.03.01 2 Moderate Limited

The time-out has the following characteristics:

- It is standardized, as defined by the hospital.

- It is initiated by a designated member of the team.

- It involves the immediate members of the procedure team, including the individual performing the procedure, the anesthesia providers, the circulating nurse, the operating room technician, and other active participants who will be participating in the procedure from the beginning.

1). Observed in Tracer Activities at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . During direct observation of a cardiac catheterization case, the first assistant did not actively participate in the time-out.

For the first half of the time-out, she was partially in the control room putting on her mask and during the second half of the time-out, she entered the room and went to a cabinet to remove supplies. The Charge RN in the Cath Lab verified this observation.

22 of 44Organization Identification Number: 9545 Final Report: Posted 2/14/2019 lih oo d to h ar m a

P at ie nt

Vi si to r / S ta ff

Program: Behavioral Health

SAFER™ Matrix

ITL

High

Moderate

Low

CTS.02.02.01 EP 1

CTS.02.02.05 EP 2

CTS.04.03.33 EP 3

CTS.02.01.11 EP 1

EC.02.06.01 EP 20

Limited Pattern Widespread

Scope

23 of 44Organization Identification Number: 9545 Final Report: Posted 2/14/2019

Program: Behavioral Health

Standard EP SAFER™ Placement EP Text Observation

CTS.02.01.11 1 Low Pattern

The organization screens all individuals served to identify those for whom a nutritional assessment is indicated. At a minimum, the screening includes questions about the following:

- Food allergies

- Weight loss or gain of ten pounds or more in the last three months

- Decrease in food intake and/or appetite

- Dental problems

- Eating habits or behaviors that may be indicators of an eating disorder, such as bingeing or inducing vomiting

1). Observed in Individual Tracer at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . During a clinical tracer in the Addiction Residential Treatment program it was observed that the nutritional status assessment did not include dental problems.

2). Observed in Individual Tracer at George E. Wahlen VA Salt Lake City Health Care System (500 Foothill Boulevard, Salt Lake City, UT) site . In an individual clinical tracer of a client in the MHICM program it was observed that the Nutrition Assessment did not include assessment of indicators of an eating…