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NORTH VALLEY HEALTH CENTER
LIFE SAFETY FROM FIRE
Tag No.: C0930
Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.
Findings include:
Please refer to the Life Safety Code inspection tags: K321, 5372, K761, K901, K 912, K918, K923 for additional information.
EP Program Patient Population
Tag No.: E0007
Based on interview and document review, the facility Emergency Management Plan (EMP) undated, failed to address the patient population including, but not limited to, patients most at-risk; the type of services the facility has the ability to provide in an emergency and continuity of operations that could be provided to those patients most at risk. This had the potential to affect all patients residing in the hospital service area.
Findings include:
During an interview on 8/21/24 at 2:00 p.m., the director of nursing identified the EMP did not identify the patient population they served.
Review of the facility Emergency Management Plan policy dated 4/2022, lacked identification of the patient population the facility served.
Roles Under a Waiver Declared by Secretary
Tag No.: E0026
Based on interview and document review, the facility failed to ensure their emergency preparedness plan (EPP) included policies and procedures to address and identify the facility's role under a waiver declared by the Secretary, in accordance with section 1135 of the Social Security Act (Act), in the provision of care and treatment at an alternate care site identified by emergency management officials during an emergency. This had the potential to affect all patients residing in the critical access hospital (CAH).
Findings include:
During an interview on 8/21/24 at 2 p.m., the director of nursing (DON) stated she was not aware of the availability of a waiver declared by the Secretary, in accordance with section 1135 of the ACT.
The facility's Emergency Management Plan policy dated 4/2022, lacked any reference to the availability of a waiver as needed declared by the Secretary, in accordance with section 1135 of the Act.