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To <br />p <br />i <br />c <br /> <br />Re <br />c <br />o <br />r <br />d <br />Se <br />l <br />e <br />c <br />t <br />i <br />o <br />n <br />Tr <br />e <br />n <br />d <br />i <br />n <br />g <br />Fr <br />e <br />q <br />u <br />e <br />n <br />c <br />y <br /> <br />Ma <br />n <br />d <br />a <br />t <br />o <br />r <br />y <br /> <br />Pe <br />r <br />c <br />e <br />n <br />t <br />a <br />g <br />e <br />of <br /> <br />Ev <br />e <br />n <br />t <br />s <br /> <br />Re <br />v <br />i <br />e <br />w <br />e <br />d <br /> <br />De <br />f <br />i <br />n <br />i <br />t <br />i <br />o <br />n <br />Da <br />t <br />a <br />So <br />u <br />r <br />c <br />e <br />Loop Closure <br />32 <br />. <br /> <br />E <br />M <br />D <br /> <br />I <br />n <br />d <br />i <br />v <br />i <br />d <br />u <br />a <br />l <br /> <br />Di <br />s <br />p <br />a <br />t <br />c <br />h <br /> <br />T <br />i <br />m <br />e <br />s <br /> <br />Al <br />l <br /> <br />9 <br />1 <br />1 <br /> <br />Ev <br />e <br />n <br />t <br />s <br /> <br />Mo <br />n <br />t <br />h <br />l <br />y <br /> <br />Ye <br />s <br />, <br /> <br />i <br />f <br /> <br />E <br />M <br />D <br /> <br />Us <br />e <br />d <br />10 <br />0 <br />% <br /> <br />o <br />f <br /> <br />A <br />l <br />l <br /> <br />Di <br />s <br />p <br />a <br />t <br />c <br />h <br />e <br />s <br /> <br />gr <br />o <br />u <br />p <br />e <br />d <br /> <br />b <br />y <br /> <br />Em <br />e <br />r <br />g <br />e <br />n <br />t <br /> <br />a <br />n <br />d <br /> <br />No <br />n <br />-Em <br />e <br />r <br />g <br />e <br />n <br />t <br /> <br />91 <br />1 <br /> <br />C <br />a <br />l <br />l <br /> <br />t <br />i <br />m <br />e <br /> <br />u <br />n <br />t <br />i <br />l <br /> <br />Di <br />s <br />p <br />a <br />t <br />c <br />h <br /> <br />o <br />f <br /> <br />E <br />M <br />S <br /> <br />U <br />n <br />i <br />t <br /> <br />f <br />o <br />r <br /> <br />ea <br />c <br />h <br /> <br />E <br />M <br />D <br /> <br />p <br />r <br />o <br />f <br />e <br />s <br />s <br />i <br />o <br />n <br />a <br />l <br /> <br />EM <br />S <br /> <br />Ag <br />e <br />n <br />c <br />y <br /> <br />Establish target and work <br />fo <br />r <br /> <br />9 <br />5 <br />% <br /> <br />c <br />o <br />m <br />p <br />l <br />i <br />a <br />n <br />c <br />e <br />33 <br />. <br /> <br />E <br />M <br />D <br /> <br />P <br />r <br />o <br />t <br />o <br />c <br />o <br />l <br /> <br />Co <br />m <br />p <br />l <br />i <br />a <br />n <br />c <br />e <br /> <br />Al <br />l <br /> <br />9 <br />1 <br />1 <br /> <br />Ev <br />e <br />n <br />t <br />s <br /> <br />Mo <br />n <br />t <br />h <br />l <br />y <br /> <br />Ye <br />s <br />, <br /> <br />i <br />f <br /> <br />E <br />M <br />D <br /> <br />Us <br />e <br />d <br />Ba <br />s <br />e <br />d <br /> <br />o <br />n <br /> <br />C <br />a <br />l <br />l <br /> <br />Vo <br />l <br />u <br />m <br />e <br /> <br />u <br />s <br />i <br />n <br />g <br /> <br />Pr <br />i <br />o <br />r <br />i <br />t <br />y <br /> <br />Di <br />s <br />p <br />a <br />t <br />c <br />h <br /> <br />Re <br />v <br />i <br />e <br />w <br /> <br />Gu <br />i <br />d <br />e <br />l <br />i <br />n <br />e <br /> <br />EM <br />D <br /> <br />C <br />o <br />m <br />p <br />l <br />i <br />a <br />n <br />c <br />e <br /> <br />p <br />e <br />r <br /> <br />EM <br />D <br /> <br />Ve <br />n <br />d <br />o <br />r <br /> <br />Q <br />u <br />a <br />l <br />i <br />t <br />y <br /> <br />Ma <br />n <br />a <br />g <br />e <br />m <br />e <br />n <br />t <br /> <br />Re <br />c <br />o <br />m <br />m <br />e <br />n <br />d <br />a <br />t <br />i <br />o <br />n <br />EM <br />S <br /> <br />Ag <br />e <br />n <br />c <br />y <br /> <br />Establish target and work <br />fo <br />r <br /> <br />9 <br />5 <br />% <br /> <br />c <br />o <br />m <br />p <br />l <br />i <br />a <br />n <br />c <br />e <br />34 <br />. <br /> <br />C <br />o <br />n <br />t <br />r <br />o <br />l <br />l <br />e <br />d <br /> <br />Su <br />b <br />s <br />t <br />a <br />n <br />c <br />e <br /> <br />C <br />o <br />u <br />n <br />t <br />s <br /> <br />Al <br />l <br /> <br />E <br />v <br />e <br />n <br />t <br />s <br /> <br />wi <br />t <br />h <br /> <br />Na <br />r <br />c <br />o <br />t <br />i <br />c <br /> <br />U <br />s <br />e <br /> <br />Mo <br />n <br />t <br />h <br />l <br />y <br /> <br />Ye <br />s <br /> <br />10 <br />0 <br />% <br /> <br />% <br />o <br />f <br /> <br />n <br />a <br />r <br />c <br />o <br />t <br />i <br />c <br /> <br />u <br />s <br />e <br />s <br /> <br />w <br />i <br />t <br />h <br /> <br />si <br />g <br />n <br />-o <br />u <br />t <br /> <br />a <br />n <br />d <br /> <br />c <br />o <br />u <br />n <br />t <br />s <br /> <br />ap <br />p <br />r <br />o <br />p <br />r <br />i <br />a <br />t <br />e <br />EM <br />S <br /> <br />Ag <br />e <br />n <br />c <br />y <br /> <br />100% of narcotic uses should be accounted for or deviation logged <br />Pa <br />t <br />i <br />e <br />n <br />t <br /> <br />C <br />a <br />r <br />e <br />: <br /> <br /> <br />T <br />r <br />e <br />a <br />t <br />m <br />e <br />n <br />t <br />35 <br />. <br /> <br />N <br />o <br /> <br />P <br />r <br />o <br />t <br />o <br />c <br />o <br />l <br /> <br />Do <br />c <br />u <br />m <br />e <br />n <br />t <br />e <br />d <br /> <br />Al <br />l <br /> <br />9 <br />1 <br />1 <br /> <br />a <br />n <br />d <br /> <br />SC <br />T <br />P <br /> <br />Ev <br />e <br />n <br />t <br />s <br /> <br />Mo <br />n <br />t <br />h <br />l <br />y <br /> <br />Ye <br />s <br /> <br />10 <br />0 <br />% <br /> <br />PC <br />R <br />’ <br />s <br /> <br />w <br />h <br />e <br />r <br />e <br /> <br />n <br />o <br /> <br />pr <br />o <br />t <br />o <br />c <br />o <br />l <br /> ( <br />o <br />r <br /> <br />o <br />n <br />l <br />y <br /> <br />Un <br />i <br />v <br />e <br />r <br />s <br />a <br />l <br /> <br />P <br />a <br />t <br />i <br />e <br />n <br />t <br /> <br />C <br />a <br />r <br />e <br /> <br />Pr <br />ot <br />o <br />c <br />o <br />l <br />) <br /> <br />i <br />s <br /> <br />l <br />i <br />s <br />t <br />e <br />d <br /> <br />Pr <br />e <br />M <br />I <br />S <br /> <br />Re <br />p <br />o <br />r <br />t <br /> <br />Set target and work for 95% compliance for protocol documentation <br />36 <br />. <br /> <br />N <br />o <br /> <br />P <br />a <br />t <br />i <br />e <br />n <br />t <br /> <br />C <br />a <br />t <br />e <br />g <br />o <br />r <br />y <br /> <br />Do <br />c <br />u <br />m <br />e <br />n <br />t <br />e <br />d <br /> <br />Al <br />l <br /> <br />E <br />v <br />e <br />n <br />t <br />s <br /> <br />Mo <br />n <br />t <br />h <br />l <br />y <br /> <br />Ye <br />s <br /> <br />10 <br />0 <br />% <br /> <br />PC <br />R <br />’ <br />s <br /> <br />w <br />i <br />t <br />h <br /> <br />no <br /> <br />( <br />E <br />0 <br />9 <br />_ <br />1 <br />1 <br />) <br /> <br />Ch <br />i <br />e <br />f <br /> <br />C <br />o <br />m <br />p <br />l <br />a <br />i <br />n <br />t <br /> <br />An <br />a <br />t <br />o <br />m <br />i <br />c <br /> <br />L <br />o <br />c <br />a <br />t <br />i <br />o <br />n <br />, <br /> <br />(E <br />0 <br />9 <br />_ <br />1 <br />2 <br />) <br /> <br />C <br />h <br />i <br />e <br />f <br /> <br />Co <br />m <br />p <br />l <br />a <br />i <br />n <br />t <br /> <br />O <br />r <br />g <br />a <br />n <br /> <br />Sy <br />s <br />t <br />e <br />m <br />, <br /> <br />( <br />0 <br />9 <br />_ <br />1 <br />3 <br />) <br /> <br />P <br />r <br />i <br />m <br />a <br />r <br />y <br /> <br />Sy <br />m <br />p <br />t <br />o <br />m <br />, <br /> <br />a <br />n <br />d <br /> <br />( <br />E <br />0 <br />9 <br />_ <br />1 <br />5 <br />) <br /> <br />Pr <br />o <br />v <br />i <br />d <br />e <br />r <br />’ <br />s <br /> <br />P <br />r <br />i <br />m <br />a <br />r <br />y <br /> <br />Im <br />p <br />r <br />e <br />s <br />s <br />i <br />o <br />n <br /> <br />D <br />o <br />c <br />u <br />m <br />e <br />n <br />t <br />e <br />d <br /> <br />Pr <br />e <br />M <br />I <br />S <br /> <br />Re <br />p <br />o <br />r <br />t <br /> <br />Set target and work for 95% compliance for documentation of these <br />re <br />q <br />u <br />i <br />r <br />e <br />d <br /> <br />d <br />a <br />t <br />a <br /> <br />e <br />l <br />e <br />m <br />e <br />n <br />t <br />s <br />. <br /> <br />37 <br />. <br /> <br />M <br />e <br />d <br />i <br />c <br />a <br />t <br />i <br />o <br />n <br /> <br />Co <br />m <br />p <br />l <br />i <br />c <br />a <br />t <br />i <br />o <br />n <br />s <br /> <br />Al <br />l <br /> <br />E <br />v <br />e <br />n <br />t <br />s <br /> <br />Mo <br />n <br />t <br />h <br />l <br />y <br /> <br />Ye <br />s <br /> <br />10 <br />0 <br />% <br /> <br />Me <br />d <br />i <br />c <br />a <br />t <br />i <br />o <br />n <br /> <br />Co <br />m <br />p <br />l <br />i <br />c <br />a <br />t <br />io <br />n <br />s <br />Do <br />c <br />u <br />m <br />e <br />n <br />t <br />e <br />d <br /> <br />in <br /> <br />P <br />C <br />R <br />Pr <br />e <br />M <br />I <br />S <br /> <br />Re <br />p <br />o <br />r <br />t <br /> <br />Discuss and address if preventable care issue. <br />38 <br />. <br /> <br />S <br />k <br />i <br />l <br />l <br /> <br />C <br />o <br />m <br />p <br />l <br />i <br />c <br />a <br />t <br />i <br />o <br />n <br />s <br /> <br />Al <br />l <br /> <br />E <br />v <br />e <br />n <br />t <br />s <br /> <br />Mo <br />n <br />t <br />h <br />l <br />y <br /> <br />Ye <br />s <br /> <br />10 <br />0 <br />% <br /> <br />Pr <br />o <br />c <br />e <br />d <br />u <br />r <br />e <br /> <br />Co <br />m <br />p <br />l <br />i <br />c <br />a <br />t <br />i <br />o <br />n <br />s <br /> <br />Do <br />c <br />u <br />m <br />e <br />n <br />t <br />e <br />d <br /> <br />in <br /> <br />P <br />C <br />R <br />Pr <br />e <br />M <br />I <br />S <br /> <br />Re <br />p <br />o <br />r <br />t <br /> <br />Discuss and address if preventable care issue. <br />No <br />r <br />t <br />h <br /> <br />C <br />a <br />r <br />o <br />l <br />i <br />n <br />a <br /> <br />C <br />o <br />l <br />l <br />e <br />g <br />e <br /> <br />o <br />f <br /> <br />E <br />m <br />e <br />r <br />g <br />e <br />n <br />c <br />y <br /> <br />P <br />h <br />y <br />s <br />i <br />c <br />i <br />a <br />n <br />s <br />St <br />a <br />n <br />d <br />a <br />r <br />d <br />s <br /> <br />f <br />o <br />r <br /> <br />t <br />h <br />e <br /> <br />S <br />e <br />l <br />e <br />c <br />t <br />i <br />o <br />n <br /> <br />a <br />n <br />d <br /> <br />P <br />e <br />r <br />f <br />o <br />r <br />m <br />a <br />n <br />c <br />e <br /> <br />o <br />f <br />EM <br />S <br /> <br />P <br />e <br />r <br />f <br />o <br />r <br />m <br />a <br />n <br />c <br />e <br /> <br />I <br />m <br />p <br />r <br />o <br />v <br />e <br />m <br />e <br />n <br />t <br />Pe <br />r <br />f <br />o <br />r <br />m <br />a <br />n <br />c <br />e <br /> <br />S <br />t <br />a <br />n <br />d <br />a <br />r <br />d <br />s <br /> <br />( <br />P <br />a <br />g <br />e <br /> <br />7 <br /> <br />o <br />f <br /> <br />1 <br />1 <br />) <br />2 <br />0 <br />0 <br />9 <br />DocuSign Envelope ID: 79C5D167-B6CA-4E59-B4AC-AA38CC1B20BD