HospitalInspections.org

Based on written document review and staff interview at the facility failed to include all of the requirements that CMS Centers for Medicare & Medicaid Services require for the facility emergency plan and policies to meet code requirements. This deficient practice affects all staff, visitors and all patients.

The findings included:

On 05/13/19 at 2 P.M. based on interview with the Administrator, there is no written documentation for the required facility federal emergency plan and policy to meet code requirements, the facility was not able to produce requested written documentation. A policy and procedure for complying with the requirements of temperatures to protect patient health & safety. An interview was conducted at this time with the Administrator, Maintenance Director and the Director of Risk Management who acknowledged that the documentation requested was not available in a written facility federal emergency plan. No additional documentation was provided at the time of exit.

The findings were acknowledged by and verified by the Administrator at the times of written document review and at the exit conference on 05/13/19.

Based on documentation and staff interview the facility failed to comply with Emergency Preparedness Plan, for maintaining temperatures. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

The finding included:

During tour of the facility and staff interview on 01/03/17 at 2:15 PM with the Maintenance Director and the Administrator it was revealed that the facility's generator does not supply air conditioning to the entire building. A policy and plan was not in place in the EPP to maintain temperatures between 71-81 degrees. Administrator and the Director of Maintenance acknowledged the absence of a plan.