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Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures include at a minimum, (1) The provision of subsistence needs for staff and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical, and pharmaceutical supplies. (ii) Alternate sources of energy to maintain - (A) Temperatures to protect patients' health and safety and for the safe and sanitary storage of provisions; (B) Emergency lighting; (C) Fire detection, extinguishing, and alarm systems; and (D) Sewage and waste disposal in accordance with 42 CFR 482.15 (b)(1). This deficient practice could affect all occupants.

Findings include:

Based on records review with the Risk Management Nurse on 11/28/23 between 1:00 p.m. to 3:00 p.m. and on 11/29/23 between 9:30 a.m. to 10:30 a.m., the subsistence needs documentation for the emergency preparedness program was incomplete. Documentation for sewage and waste outage was not available for review. Based on interview at the time of records review, the Risk Management Nurse stated the aforementioned policy could not be found.

This finding was reviewed with the Quality Coordinator, Inpatient Director, HR director and, the Risk Management Nurse during the exit conference.

Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures include a system to track the location of on-duty staff and sheltered patients in the facility's care during and after an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the facility must document the specific name and location of the receiving facility or other location in accordance with 42 CFR 482.15(b) (2). This deficient practice could affect all occupants.

Findings include:

Based on records review with the Risk Management Nurse on 11/28/23 between 1:00 p.m. to 3:00 p.m. and on 11/29/23 between 9:30 a.m. to 10:30 a.m., a policy and procedure that includes a system to track the location of on-duty staff and patients in the facility's care during and after an emergency was not available for review. Based on interview at the time of record review, the Risk Management Nurse stated the facility did not have a policy and procedure for tracking patients and staff during an emergency.

This finding was reviewed with the Quality Coordinator, Inpatient Director and, the Risk Management Nurse during the exit conference.

Based on record review and interview, the facility failed to ensure emergency preparedness plan (EPP) include a means to shelter in place for patients, staff, and volunteers who remain in the facility in accordance with 42 CFR 482.15(b)(4). This deficient practice could affect all occupants.

Findings include:

Based on records review with the Risk Management Nurse on 11/28/23 between 1:00 p.m. to 3:00 p.m. and on 11/29/23 between 9:30 a.m. to 10:30 a.m., the facility's EPP did not provide complete full written procedures for sheltering in place for patients, staff, and volunteers. Based on interview at the time of records review, the Risk Management Nurse stated there was not a sheltering in place policy that listed full procedures.

This finding was reviewed with the Quality Coordinator, Inpatient Director and, the Risk Management Nurse during the exit conference.

Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures (EPP) include the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State or Federally designated health care professionals to address surge needs during an emergency in accordance with 42 CFR 482.15(b)(6). This deficient practice could affect all occupants.

Findings include:

Based on records review with the Risk Management Nurse on 11/28/23 between 1:00 p.m. to 3:00 p.m. and on 11/29/23 between 9:30 a.m. to 10:30 a.m., the provided EPP did not address the use of volunteers in an emergency. Based on interview at the time of records review, the Risk Management Nurse stated there was not a policy on the use of volunteers in an emergency provided in the EPP.

This finding was reviewed with the Quality Coordinator, Inpatient Director and, the Risk Management Nurse during the exit conference.

Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures (EEP) include the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials in accordance with 42 CFR 482.15(b) (8). This deficient practice could affect all occupants.

Findings include:

Based on records review with the Risk Management Nurse on 11/28/23 between 1:00 p.m. to 3:00 p.m. and on 11/29/23 between 9:30 a.m. to 10:30 a.m., a complete policy and procedure for the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act was not available for review. There was a sentence that stated, "If a 1135 waiver is declared, the facility will cooperate with emergency management personnel," but information on the policies or procedures were not stated. Based on interview at the time of record review the Risk Management Nurse acknowledged the1135 waiver policy was incomplete.

This finding was reviewed with the Quality Coordinator, Inpatient Director and, the Risk Management Nurse during the exit conference.

Based on record review and interview, the facility failed to ensure the emergency preparedness communication plan includes (4) A method for sharing information and medical documentation for residents under the facility's care, as necessary, with other health care providers to maintain the continuity of care; (5) A means, in the event of an evacuation, to release resident information as permitted under 45 CFR 164.510(b)(1)(ii); (6) A means of providing information about the general condition and location of residents under the facility's care as permitted under 45 CFR 164.510(b)(4) in accordance with 42 CFR 482.15(c)(4). This deficient practice could affect all occupants.

Findings include:

Based on records review with the Risk Management Nurse on 11/28/23 between 1:00 p.m. to 3:00 p.m. and on 11/29/23 between 9:30 a.m. to 10:30 a.m., the emergency preparedness communication plan did not include a method for sharing information and medical documentation for residents under the facility's care, as necessary, with other health care providers to maintain the continuity of care. Based on interview at the time of record review, the Risk Management Nurse stated the method for sharing information policy was not in the emergency preparedness communication plan.

This finding was reviewed with the Quality Coordinator, Inpatient Director and, the Risk Management Nurse during the exit conference.

Based on record review and interview, the facility failed to ensure the emergency preparedness communication EPP plan includes a means of providing information about the facility's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction or the Incident Command Center, or designee in accordance with 42 CFR 482.15(c)(7). This deficient practice could affect all occupants.

Findings include:

Based on records review with the Risk Management Nurse on 11/28/23 between 1:00 p.m. to 3:00 p.m. and on 11/29/23 between 9:30 a.m. to 10:30 a.m., the provided EPP communication plan did not address a means of providing information about the facility's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction or the Incident Command Center, or designee. Based on interview at the time of records review and during exit conference, the Risk Management Nurse looked through the EPP and could not find a plan that addressed a means of providing information about the facility's occupancy, needs, and its ability to provide assistance.

This finding was reviewed with the Quality Coordinator, Inpatient Director and, the Risk Management Nurse during the exit conference.