o Would it be useful to identify the core issue of the risk being addressed? In the month of July, 4 teams noted inability to safely evacuate from the home. Although this is risk, it is unclear why. If teams were to implement the 5 why’s, could they drill down to the core issue. For example, if the inability to evacuate was due to mobility, could we identify DME to mitigate that risk. If the core issue is identified as blocked walkways limiting access, then discussion and plans can occur around that specific risk. It has also been noted that being one’s own person and non-nursing home level of care as a risk factor. Again, if the core issue is identified, would we be more successful working with members to mitigate the specific risk.