Every finding on record at Health Watch Hospice of Utah Inc

Based on interview and record review, it was determined that the hospice agency had not participated in a full-scale exercise that is community-based every 2 years; or when a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years. Additionally, the hospice agency did not maintain documentation of an analysis of the facilitys response to drills, tabletop exercises, and emergency events and revise the facility's emergency plan, as needed. --- Findings include: During a recertification survey conducted between 3/13/2023 and 3/15/2023, surveyors requested the following: a. Emergency preparedness plan and risk assessments b. Emergency preparedness policy and procedures c. Emergency preparedness communication plan d. Documentation of emergency preparedness training of staff e. Documentation of annual emergency preparedness exercises conducted On 3/15/2023, a review of the agencys emergency preparedness drills was completed and revealed the following: The agency completed a tabletop emergency preparedness exercise on 10/18/2022. The document that was provided was an in-service titled, ";Review Emergency Preparedness and Calling Tree." The document contained a sign in sheet and then a policy on how to respond to an outbreak of influenza. There was no documentation of an analysis or after-action review of the drill. Additionally, no documentation could be provided to indicate that the agency had participated in a full-scale community-based emergency preparedness exercise or a facility-based functional exercise. On 3/15/2023, at 9:30 AM, an interview was conducted with the administrator. The administrator stated, ";I was not aware that we need to conduct an exercise each year." The administrator further stated, ";we have not participated in a full-scale community-based emergency preparedness exercise, because they have not been available." On 3/14/2023 at 3:08 PM, an email was received from the administrator that stated ";Emergency Preparedness is done according to regulation, every 2 years. We did one in 2020 and 2022."