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Based on a Validation survey, review of the Emergency Preparedness Program (EPP) performed on 10/24/2018 at 10:00 am with the Security Director (employee #21), it was determined that the facility failed to develop and maintain an emergency preparedness plan that include a process for cooperation and collaboration to maintain a respond during a disaster or emergency situation.

Findings include:

During the EP survey performed on 10/24/2018 at 10:00 am, it was found that the facility did not provide evidence of the facility's efforts to contact the different emergency agencies such officials, dates or documentation related to this communications.

Based on a Validation survey, review of the Emergency Preparedness Program (EPP) performed on 10/24/2018 at 10:00 am, review of the Contingency Plan requirements, it was determined that the facility failed to develop and maintain an emergency preparedness plan that include policies and procedures (P&P's)for sheltering during a disaster or emergency situation.

Findings include:

1. During the EP survey performed on 10/24/2018 at 10:00 am, it was found that the facility did not have an emergency preparedness that include policies and procedures (P&P's) for sheltering during a disaster or emergency situation.

2. The facility did not provide evidence of the facility's policies and procedures (P&P's) for sheltering during a disaster or emergency situation.

Based on a Validation survey, review of the Emergency Preparedness Program (EPP) performed on 10/24/2018 at 10:00 am with the Security Director (employee #21), to evaluate emergency preparedness requirements, it was determined that the facility failed to develop policies and procedures for medical documentation that preserves patient information, protects confidentiality of patient information and secures and maintains availability of records.

Findings include:

During the survey performed on 10/24/2018 at 10:00 am with the Security Director (employee #21),it was found that the facility did not have policies and procedures related to preserves patient information, protects confidentiality of patient information and secures and maintains availability of records.

Based on a Validation survey, review of the Emergency Preparedness Program (EPP) performed on 10/24/2018 at 10:00 am to evaluate emergency preparedness requirements, it was determined that the facility failed to develop policies and procedures to arrangements with other hospitals in event of limitations or cessation of operations to maintain the continuity of services.

Findings include:

During the survey performed on 10/24/2018 at 10:00 am, provide evidence that the facility did not developed and implement emergency preparedness policies and procedures for the arrangements with other facilities and other providers to receive patients in case of limitation or cessation of operations.

Based on a Validation survey, review of the Emergency Preparedness Program (EPP) performed on 10/24/2018 at 10:00 am, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain an emergency preparedness training program.

Findings include:

1. No evidence of initial training in emergency preparedness policies and procedures to all new and existing facility employees and individuals providing services under arrangement, consistent with their expected roles.

2. No evidence of documentation related to if the staff demonstrate knowledge of emergency procedures.