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UF HEALTH LEESBURG HOSPITAL
Develop EP Plan, Review and Update Annually
Tag No.: E0004
Based on observation and interview, the facility failed to ensure the Emergency Preparedness Plan was available for review.
Findings included:
During the entrance on 06/01/2021 at 9:15 AM, the Director of Risk Management stated the facility has been hit probably by ransomware last night and there is no way to do medical chart review or get lists. A request was made to the Director of Risk Management for the Emergency Preparedness Plan to verify the plan was developed and maintained a comprehensive emergency preparedness program that meets the requirements. The Emergency Plan was not provided.
A request was made to the Director of Risk Management on 06/01/2021 at 10:00 AM to review the Emergency Preparedness Plan. The Emergency Plan was not provided.
During an interview on 06/01/2021 at 1:30 PM, with the Vice President (VP)/Chief Quality Officer (CQO) when asked regarding the possible ransomware event the CQO stated, this started last night, 05/31/2021, at around 9:00 PM. The Information Tech (IT) for the hospital noted a problem with the Electronic Medical Record (EMR) system within the computer program. The IT person spoke with the main hospital and that hospital was not experiencing any problems. Our IT spoke with the IT at one of our sister hospitals at around 10:00 PM. They were having concerns and the computer systems were discontinued for these two hospitals. At around 11:00 PM it was decided to have both hospitals sever the main computer system from the main hospital. The CQO stated the EMR was down after 11:00 PM. All patients' records are backed up. There is no evidence of patients' medical records being breached at this time.
A request was made on 06/01/2021 at 2:00 PM, with the Director of Risk Management to review the Emergency Preparedness Plan. The Emergency Plan was not provided.
A request was made on 06/02/2021 at 10:00 AM, with the Director of Risk Management to review the Emergency Preparedness Plan. The Emergency Plan was not provided.
A request was made on 06/02/2021 at 11:40 AM, with the Director of Risk Management to review the Emergency Preparedness Plan. The Emergency Plan was not provided.
A request was made on 06/02/2021 at 1:30 PM, prior to exiting the hospital, with the Director of Risk Management to review the Emergency Preparedness Plan. The Emergency Plan was not provided.