PRINTED 08/23/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO _0936.0391 [STATEMENTOF DEFICIENCIES (x1) PROVIDERSUPPLERICLIA | ok MULTIPLE CONSTRUGTION ox) ovTe SURVEY [AND PLAN OF CORRECTION IDENTIRCATIONNUMBER — | automa COMPLETED c 460051 8 wc —__ 08/0612019 THANE OF PROVIDER OR SUPPUER “STREETADORESS, CIN, STATE, P CODE ‘3580 WEST 9000 SOUTH JORDAN VALLEY MEDICAL CENTER Wear bcenanl Uriesne oa ‘SURRUARY STATBIENT OF DEACENGIES To PROVIDER'S PLAN OF CORRECTION @, Fier | (act DEFICIENCY MUST BE PRECEDED BY FULL PREFX (EACH CORRECTWEACTION SHOULD BE, coutnow “Ae | REGULATORVOR LSC IDENMIFMING INFORMATION, — | Tag ‘CROSS REFERENCED TOTME APPROPRIATE‘ "OAT \ DEAGIENGY) ¥ ‘A000 INITIAL COMMENTS A000! : ' ‘An abbreviated validation complaint survey was POC acceptable 9/12/19 eee ' latest correction date 10/4/19: + On 7/31/49, a finding of immediate Jeopardy (J) } was identified i the area of Infection Control Adsena Go ' The hospital was notified ofthis finding on 7/34/19 at approximately 5 30 PM. The Hosptal submitted an IJ removal/abatement plan on ' 8/1/19 at 8 31 AM, alleging removal as of 8/1/19 ' at 55 AM. The plan was accepted and the hospital was notified at 8 52 AM on 8/1/19 | Surveyors were on site and reviewed for 1J | femoval It was determined that lJ had been removed on 8/1/19 at 6 55 AM as indicated in the | ' | removal plan, the hospital was notified ofthis at 440 PM on 8/1/19 Deficiencies were identified in the areas of Infection Control and Governing Body 1 ‘A043 GOVERNING BODY A043) : CFR(s) 482 12 ' 1 There must be an effective governing body that 1s | legally responsible for the conduct of the hospital ! Ifa hospital does not have an organized : governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the | governing body {Ths CONDITION 1s not metas evidenced by i Based on interview and record review, twas determined the hospital's governing body ; (GByfated to ensure the infection control program | ‘Was integrated to include al three campuses ! "Iisted under their provider number and that their Infection control program was functioning LABORATORY DIRECTOR S OR PROVIDER/SUPPLIER REPRESENTATIVES SIGNATURE, ThE BaiDAE astiom fastiner 9.5. Ped ‘Ray daiconcy staloment ending with an astorgk ()adhotes a dticency which the Ineuiubon may be excused from correcing proving Wis determined hat ‘ther safeguards prone suicient protection to the pallets (Swe Instructions ) Excop for nursing homes, the ndings stated above are disclosable 90 daye following te date of survey whether or not a plan of corecion is prewded For nursing homes, the above findings and plans of cotetion are dsciosable 14 days folowing the date these documents are made avaliable to he fecily Hf deiclendles are cted an approved plan of correction srequsite to continued program partopaton Font cMS- 250710245 Prevous Vrwans Obie Event 0 SaNTHI acy © UT480081 Weontinuation sheet Page 1 of34Jordan Valley Medical Center _ Jordan Valley Medical Center West Valey Campus Mountain Point Medical Center ‘A Campus of Jordan Valley Medical Center September 5, 2019 Utah Department of Health Bureau of Health Facility Licensing Certification and Resident Assessment Attn Joel Hoffman PO Box 144103 SLC, Utah 84114-4103 Dear Mr Hoffman Tam writing regarding the unannounced CMS survey which was completed at Jordan Valley Medical Center from July 31, 2019 through August 6, 2019 Enclosed you will find ‘© The first page of the CMS form 2567 received from Kimmune Hudson with CMS that has been executed with my signature and date * Acdocument which outlines the statement of deficiencies and the corresponding plan of correction Thave e-mailed a copy of these documents to Sheila Edwards at Sheilaedwards@utah gov and to Kimmine Hudson at Kimmine Hudson@cms hhs gov Please contact me with any questions or concerns Best regards, bo Bo Jon Butterfield, Hospital President 801-562-4210 Office 801-783-8458 Cell Jon butterfield@steward org, Jordan Valley Medical Center 3580 West 000 Soutn West Jordan Utah 840865 | Tel BOL-561 8888 | jodarvaleyme org Jordan Valley Medical Conter-West Valley Campus 2460 South 4155 West Was! Vay Cty Utan 84120 | Tel BOL 964 3100 | yrdarwestvatoy ons Mountam Point Medical Center 2000 North Tough Boulevart Ley Utah 4043 | Tel 385 345 2000 | mouotainantmedealcenter og In Partnersup with Physician OwnersPRINTED 08/23/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES. FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO_0938.0391 STATEMENT OF DEFICIENCIES 1) PROVIDERISUPPLIERICLA |p) MULTIPLE CONSTRUCTION xs) oaTE survey AND PLAN OF CORRECTION IDENTFRCATON NUMBER | ao ‘cOUPLETED c 450051 8 wwe 08/06/2019 TARE OF PROTDER OR SUPPER ‘SYREETADORESS OMY STATE UP CODE 13580 WEST 9000 SOUTH JORDAN VALLEY MEDICAL CENTER EST ioecanUsToiees w0 ‘SORRIARY STATENENT OF DEFICIENCIES © PROVIDERS PLAN OF CORRECTION @, Prem | GACH DEFICIENCY MUST BE PRECEDED BY FULL PRED eacnconrecrwve action snouLb ae -|'contttron Tee" | Hesonveriaeieenne roma TAC, | CHOSSREFERENCED TO ME APPROPRIATE "ONE | DEFICIENCY) A000] INITIAL COMMENTS ‘A000 ‘An abbreviated validation complamnt survey was , Conducted from 7/31/19 through 8/6/19, | On 7/34/19, a finding of Immediate Jeopardy (Wd) | was identified in the area of Infection Control The hospital was notified of this finding on | 7/31/19 at approximately 5 30 PM The Hospital submitted an |J removal/abatement plan on 8/1/19 at 8 31 AM, alleging removal as of 8/1/19 at6 55AM The plan was accepted and the hospital was notified at 8 52 AM on 8/1/19 | j Surveyors were on site and reviewed for IJ removal It was determined that IJ had been removed on 8/1/19 at 6 55 AM as indicated in the | removal plan, the hospital was notified of this at 4.40 PM on 8/1/19 | Deficiencies were identified inthe areas of ! Infection Control and Governing Body ‘A043. GOVERNING BODY A083 CFR(s) 48212 | There must be an effective governing body that is legally responsible for the conduct of the hospital if hosptal does not have an organized ; ‘goveming body, the persons legally responsible ; i [or the conduct of the hospital must carry out the fencons spected In this part that pertain to the RECEIV! ED ‘This CONDITION 1s not met as evidenced by | Based on interview and record review. i was SEP 09 2019 determined the hospital's governing body (GB)falled to ensure the infection control program, Heath Ream ct Heat was integrated to clude al hree campuses aero ees iisted under their provider number and that their iesoon Infection control program was functioning URBORRTORY OREGTORS OF PROVOERSUPPUER REPRESENTATWES HONATORE THE Tarn seco laetinen 9.5 2019 Kay defiency statement ending wih an astensk () ddhotes a deficency whch the nebiulon may be excused From corecing pronaing hs determined Tet ther safeguards provide suficint protecion to the patents (See instructions ) Except for nursing homes the fncings state above are dclosable 90 days \ toong the date of survey whether or nata plan of eorrecton e proved For nuramg Nomes the above ndings end plan of correction are dsclosable 14 days folowing the date these documents are made avaliable to the fly I deficiencies are etled an approved plan of correction i equate to continued rogram participation For ems-25676 Wontnaton sheet Page 1 of 34 5) Peneus Versane CbeieteJordan Valley Medical Center-460051 Response to Survey Completed 8.6.2019 Statement of Deficiencies TAG | DEFICIENCY PLAN OF CORRECTION MONITORING | RESPONSIBLE | COMPLETION PERSON, DATE ‘043 | GOVERNING BODY Jordan Valley Medical Center, Jordan Valley Medical] Allactions taken will | Hospital President | 10419 ‘There must be an effective governing body that 1s legally responsible for the conduct ofthe hospital Ifa hosputal does not have an organized ‘governing body, the persons legally responsible forthe conduct of the hospital must earry out the functions specified in this part that pertain to the ‘governing body This CONDITION 1s not met as evidenced by Based on mterview and record review, rt was determined the hospital's governing body (GB)fatled to ensure the infection control program ‘was integrated to mclude all three campuses listed under their provider ‘number and that thear infection control program was functioning ‘The GB also failed to ensure that all ‘campuses of the hospital were ‘monitored and overseen as part of the ‘overall hosprtal operations Center - West Valley Campus and Mountain Point Medical Center operate under the direction of a single Governing Board (GB) The composition of the GB includes representatives of the three communes served by each of the campuses as well as physicians on the medical staff at each facility The plan was reviewed and revised to melude 3 Risk Assessments, one for each site July 31, 2019 The GB was notified of the CMS survey, the notification of immediate jeopardy status and the plan to mitigate the IJ status ‘© The Medical Staff President and GB member was, notified by Hospital President on July 31, 2019 ‘¢ The GB Chatr, was on vacation, but was notified via text message by the Medical Staff President ‘on July 31, 2019 ‘© The Chief Medical Officer (CMO) of Utah Region for Steward Healthcare and JVMC GB ‘member, was notified by Hospital President on July 31, 2019 August 1, 2019 The Governing Board (GB) was notified ‘when the hospital recerved notification thatthe IJ status had been lifted ‘© Medical Staff President was notified by Hospital President © GB Chair remained on vacation but was notified by text message by Medical Staff President © CMO was notified by Hospital President ‘August 9, 2019 Hospital President, met with GB Chair and CMO The unannounced survey was discussed in detail with the expected condition level findings, the hosprtal’s immediate actions to address the condition level findings and the hospital's plan of correction. GB Chair approved of the actions taken by hospital leadership and be reported in the regularly scheduled GB meetings and documented in meeting minutes, RECEIVED SEP 9 Heath Fac and: 2019 Licensing