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Based on the facility's policy/procedure, documents, observation on tour, and interviews, it was determined that the facility failed to require that two (2) medication refrigerators, and one (1) medication freezer had temperatures recorded twice daily during clinic hours, as required. This deficient practice poses a risk to the health, and safety of the patient(s), when the facility does not record the temperatures of the medication refrigerators, and medication freezer ensuring that medications are stored according to the manufacturer's guidelines, maintaining the efficacy of the medications.

Findings include:

Policy titled "Performance Improvement Plan" (#R-1-2013; 10/2020), revealed: "...to improve performance...setting priorities for improvement...objective...improve the quality of the work environment...Quality Assurance personnel...manages the performance improvement activities...team leaders will continuously monitor the key functions in their departments...generally recognized standards of care...medication administration....."

Documents reviewed on 11/16/2020, revealed the following:

i. Refrigerator Temperature Log (Vaccines), November 2020: Five (5) temperatures not recorded;

ii. Refrigerator Temperature Log (Antigens), November 2020: Five (5) temperatures not recorded;

iii. Refrigerator Temperature Logs (x2, refrigerator name not listed on the logs), September 2020: Twenty-four (24) temperatures not recorded;

iv. Refrigerator Temperature Logs (x2, refrigerator name not listed on the logs), October 2020: Nineteen (19) temperatures not recorded;

v. Freezer Temperature Logs, September, October and November 2020: Twenty-six (26) temperatures not recorded.

Observation on tour conducted 11/16/2020 (1300), identified two (2) medication refrigerators (used separately for antigens and vaccines), and one (1) medication freezer. The medication refrigerator (antigen), was locked, and located in the hallway near Exam Room #1. The medication refrigerator (vaccine), was locked, and located in the medication room. The medication freezer was locked, and located behind the nurse's station. It was identified that each medication refrigerator, and medication freezer had individual November 2020 temperature logs. Additionally, the September and October 2020 medication refrigerator temperature logs, and September and October 2020 medication freezer logs were requested and provided.

The surveyor requested a policy/procedure specific to the requirement for maintaining medication temperature and medication freezer temperature logs, and none was provided.

Employee #13 confirmed during an interview conducted 11/16/2020 (1300), that the two (2) medication refrigerators, and medication freezer temperature checks are to be done twice daily on clinic days, and recorded on the temperature log sheets. Additionally, Employee #13 revealed that the two (2) medication refrigerators, and the medication freezer were missing the required temperature checks as identified on the September, October, and November 2020 log sheets.

Employee #2 confirmed during an interview conducted 11/18/2020 (1015), that the facility did not have a policy/procedure specific to the requirement of maintaining medication refrigerator temperature and medication freezer temperature logs.

Based on record review and staff interview, the facility failed to address patient/client risks and did not have a succession plan as part of the continuity of operations. This places the at risk population at risk of not getting the proper care due to lack of resources being available for their needs and creates an opportunity for confusion during an emergency.

[E-0007] 482.15(a)(3) EP Program Patient Population

Address patient/client population, including, but not limited to persons at-risk, the type of services the hospital has the ability to provide in an emergency, and continuity of operations, including delegation of authority and succession plans .

Findings include:

The facilities Emergency Preparedness documents were reviewed on November 17,2020 it was reveled the facility's Emergency Preparedness Plan did not contain documents addressing the at risk population and were unable to locate any documentation of strategies to address the needs of those patients/clients. In addition the hospital did not have a policy in place for delegation of authority and succession.

Employees #1, #28 and #49 acknowledged during the exit interview conducted on November 18, 2020 that the facilities Emergency Preparedness Plan did not contain documents addressing the at risk population and were unable to locate any documentation of strategies to address the needs of those patients/clients. In addition the hospital did not have a policy in place for delegation of authority and succession.