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Based on interviews and review of facility documentation, the facility failed to ensure compliance for the Condition of Participation (CoP) for the Emergency Preparedness Plan (EPP) as evidenced by the failure to 1) document a review and update the EPP annually; 2) have an EPP based on a facility Risk Assessment; 3) EPP does not have documentation of collaboration or documented efforts of contact and participation in collaborative and cooperative planning efforts with Federal officials; 4) develop policies based on a facility and community Risk Assessment, and documentation the policies were reviewed and updated annually; 5) ensure the EPP evacuation plan included a procedure for tracking of patients and staff; 6) ensure the EPP included a policy for volunteer use in emergent situations; 7) ensure the EPP policies and procedures addressed arrangements with other facilities and providers; 8) ensure the EPP addressed a 1135 waiver; 9) ensure the Communication Plan had a documented annual review and update; 10) ensure the Communication Plan contained contact information for other facilities and providers, and a documented annual review and update of that contact information; 11) ensure the Communication Plan included regional, state, and federal emergency preparedness contacts and the contacts had a documented annual review and update; 12) ensure the Communication Plan included a primary and alternate means of communication with facility staff; 13) ensure the Communication Plan included a method for releasing and sharing patient information. These failures had the potential to affect all seven facility in-patients and/or swing bed patients, and/or out-patients receiving care in the facility, and potentially hinder the facility's ability to prepare for potential emergency situations and keep patients safe during an emergency.

Findings Include:

1. The facility failed to ensure the EPP had a documented annual review and update. Refer to E-0004.

2. The facility failed to ensure the EPP was based on a facility Risk Assessment. Refer to E-0006.

3. The facility failed to ensure the EPP had documentation of collaboration or documented efforts of contact and participation in collaborative and cooperative planning efforts with Federal officials. Refer to E-0009.

4. The facility failed to develop policies based on a facility and community Risk Assessment, and documentation the policies were reviewed and updated annually. Refer to E-0013.

5. The facility failed to ensure the EPP evacuation plan included a procedure for tracking of patients and staff in an emergency. Refer to E-0018.

6. The facility failed to ensure the EPP included a policy regarding the use of volunteer help in the case of emergency. Refer to E-0024.

7. The facility failed to ensure the EPP policies and procedures addressed arrangements with facilities and providers in an emergent event. Refer to E-0025.

8. The facility failed to ensure the EPP addressed a 1135 waiver by the Secretary of Health. Refer to E-0026.

9. The facility failed to ensure the Communication Plan had a documented annual review and update. Refer to E-0029.

10. The facility failed to ensure the Communication Plan contained contact information for other facilities and providers, and a documented annual review and update of that contact information. Refer to E-0030.

11. The facility failed to ensure the Communication Plan included regional, state, and federal emergency preparedness contacts, and that the contacts had a documented annual review and update. Refer to E-0031.

12. The facility failed to ensure the Communication Plan (CP) identified a primary and alternate means of communication with facility staff during an emergency. Refer to E-0032.

13. The facility failed to ensure the Communication Plan included a method for releasing and sharing patient information in an emergent situation. Refer to E-0033.

In an interview on 01/17/19 at 4:30 PM, the Chief Executive Officer stated an awareness of the Emergency Preparedness regulations and the Kansas Hospital Association was really starting to assist facilities with the development of an Emergency Preparedness Plan.

The facility was unable to provide a general policy regarding the Emergency Preparedness Program.

Based on interview and review of the facility's Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP was reviewed and updated annually. This failure had the potential to affect the seven patients receiving care in the facility and hindered the facility's ability to provide care and services to patients and keep patients safe during an emergency.

Findings Include:

Review of the facility's EPP on 01/16/19 at 1:30 PM failed to identify documentation the facility's EPP was reviewed annually.

In an interview on 01/16/19 at 1:35 PM, the Emergency Coordinator stated, "there was no annual review and update [of the EPP]."

Based on interview and review of the facility's Emergency Preparedness Plan (EPP) documentation, the facility failed to ensure the EPP was based and included a documented, facility and community based risk assessment. This failure had the potential to affect the seven patients receiving care in the facility and hindered the facility's ability to prepare for potential emergency situations and keep patients safe during an emergency event.

Findings Include:

Review of the facility's EPP on 01/16/19 at 1;30 PM failed to identify the EPP was based on a facility-based and community- based risk assessment. Further review of the EPP did not identify strategies were developed based on the use of a risk assessment.

In an interview on 01/16/19 at 1:49 PM, the Emergency Coordinator stated a Risk Assessment had not yet been completed by the facility.

Based on interview and review of the facility's Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP contained documentation of collaboration, or documented efforts of contact and participation in collaborative and cooperative planning efforts with federal emergency preparedness officials. This failure had the potential to affect the seven patients receiving care in the facility and hindered the facility's ability to prepare for potential emergency situations and keep patients safe during an emergency event.

Findings Include:

Review of the facility's EPP on 01/16/19 at 1:30 PM did not include documentation of collaboration with federal emergency preparedness officials. Further, documentation was lacking regarding efforts to contact and participate in collaborative and cooperative planning efforts with federal emergency preparedness officials.

In an interview on 01/16/19 at 2:10 PM, the Emergency Coordinator stated there was local, regional and state collaboration, however, no federal contact and/or participation was in the EPP.

Based on interview and review of the facility's Emergency Preparedness Plan (EPP), the facility failed to develop and implement emergency preparedness policies and procedures based on a facility risk assessment, that included but not limited to, fire, equipment, power, or water failure; care related emergencies; and natural disasters likely to threaten the health or safety of patients, staff, or the public that have been reviewed and updated on an annual basis. This failure had the potential to affect the seven patients receiving care in the facility and hindered the facility's ability to provide care and services during an emergency event and keep patients safe.

Findings Include:

Review of the facility's EPP on 01/16/19 at 1:30 PM did not reveal policies and procedures based on but not limited to fire, equipment, power, or water failure; care related emergencies; and natural disasters likely to threaten the health and safety of the patients, staff, or the public that were reviewed and/or updated annually.

In an interview on 01/16/19 at 2:12 PM, the Emergency Coordinator stated the policies and procedures of the disaster plan were not based on a facility or community risk assessment, and there was no documented annual review and update.

Based on interview and review of the facility's Emergency Preparedness Plan (EPP) evacuation plan, the facility failed to ensure the evacuation plan included a process for tracking patients and staff in an emergent situation. This failure had the potential to affect the seven patients receiving care in the facility, any staff on duty; and hindered the facility's ability to prepare for potential emergency situations and keep patients safe during an emergency.

Findings Include:

Review of the facility's Emergency Preparedness evacuation plan on 01/16/19 at 1:30 PM, did not reflect that a process was developed to identify how patients and staff would be tracked in the event of an emergency evacuation.

In an interview on 01/16/19 at 2:35 PM, the Emergency Coordinator stated there was a policy to track patients and staff, but no method or procedure was included in the Emergency Preparedness Plan.

Review of the undated "Evacuation - Emergent and Progressive" policy revealed: "Emergent: Procedure: Emergent: Life Safety Threat 1. Immediate lifesaving evacuations will be activated by affected hospital staff.
17. As soon as possible, a tracking log should be started for documenting patients, visitors, and staff.
Progressive: Situation is less emergent but still dangerous but allows time for Lincoln County Hospital to evacuate.
11. A tracking log should be started for documenting patients, visitors and staff.

Based on interview and review of the facility's Emergency Preparedness Plan (EPP), the facility failed to develop a policy for the use of volunteer assistance in an emergency. This failure had the potential to affect the seven patients receiving care in the facility and hindered the facility's ability to provide care and services to patients and keep patients safe during an emergency.

Findings Include:

Review of the facility's Emergency Preparedness Plan on 01/16/19 at 1:30 PM did not reveal a policy regarding how the facility would use volunteer staff/assistance as part of operations during an emergency.

In an interview on 01/16/19 at 2:59 PM the Emergency Coordinator stated, "We don't have a policy for volunteer use."

Based on review of the facility's Emergency Preparedness Plan (EPP), the policies and procedures failed to address arrangements with other facilities and/or providers in case of emergency. This failure had the potential to affect the seven admitted patients receiving care in the facility, any staff on duty; and hindered the facility's ability to prepare for potential emergency situations and keep patients safe during an emergency event.

Findings Include:

A review of the facility's EPP on 01/16/19 at 1:30 PM did not reveal a policy regarding the arrangements with other facilities and/or providers regarding receipt of patients in the event the facility is unable to care for them during an emergency.

In an interview on 01/16/19 at 3:00 PM, the Emergency Coordinator stated the EPP does not have copies regarding arrangements or agreements.

In an interview on 01/17/19 at 4:30 PM, the Chief Executive Officer stated the facility does have contracts, just probably not in the disaster plan.

Based on interview and review of the facility's Emergency Preparedness Plan (EPP), the facility failed to include the role of the facility if a waiver was declared in accordance with section 1135 of the Social Security Act. This failure had the potential to affect the seven patients receiving care in the facility and hindered the facility's ability to provide care and services and keep patients safe during an emergency.

Findings Include:

Review of the facility EPP on 01/16/19 at 1:30 PM did not reveal any policy or procedure regarding the role of the facility if the Health and Human Services Secretary should declare a section 1135 waiver.

In an interview on 01/16/19 at 3:10 PM, the Emergency Coordinator stated there was nothing in the policies regarding a 1135 waiver.

Based on interview and review of the facility's Emergency Preparedness Plan (EPP), the facility failed to develop and maintain a Communication Plan that was reviewed and updated annually. This failure had the potential to affect the seven patients receiving care in the facility and hindered the facility's ability to continue care and services to patients during an emergency and keep patients safe.

Findings Include:

Review of the facility Emergency Preparedness Communication Plan on 01/16/19 at 1:30 PM did not reflect the Emergency Preparedness Communication Plan had been reviewed and updated annually as necessary.

In an interview on 01/16/19 at 3:11 PM, the Emergency Coordinator stated there was no documentation the Communication Plan was reviewed and updated annually.

Based on interview, and review of the facility's Emergency Preparedness Plan (EPP), the facility failed to maintain a current list of names and contact information in the Emergency Preparedness communication plan that included entities providing services under arrangement and other facilities. This failure had the potential to affect the seven patients receiving care in the facility and hindered the facility's ability to prepare for potential emergency situations and keep patients safe.

Findings Include:

Review of the facility Emergency Preparedness Communication Plan on 01/16/19 at 1:30 PM did not reveal a list of the names and contact information for entities that provide assistance under an arrangement.

In an interview on 01/16/19 at 3:17 PM, the Emergency Coordinator stated the names and contact information were not included in the Communication Plan.

Based on interview and review of facility documentation the facility failed to maintain a current list of contact information including the federal, state, and local emergency preparedness staff and agencies in their Emergency Preparedness Communication Plan. This failure had the potential affect the seven patients receiving care in the facility and would delay the facility's ability to respond to an emergency. This failure had the potential to prevent first responders and other sources of assistance from providing care and services to the facility and its patients during an emergency event.

Findings Include:

Review of the facility Emergency Preparedness Communication Plan on 01/16/19 at 1:30 PM did not include contact information for regional, state and/or federal agencies. The review also did not reveal documentation that the local agencies listed were reviewed and updated annually.

In an interview on 01/16/19 at 3:20 PM, the Emergency Coordinator (EC) stated "I can't think of where they would be listed, so [the contact information is] probably not included in the Communication Plan." The EC also stated there was no evidence of an annual review or update.

Based on interview and review of the facility documentation failed to define the primary and secondary means of communication used in the facility's Emergency Preparedness Plan that defined how the facility would communicate with staff members, physicians, entities providing services under arrangement, and emergency preparedness agencies during an emergency. This failure had the potential to affect the seven patients in the facility and would hinder the facility from providing care and services during an emergency event.

Findings Include:

Review of the facility's Emergency Preparedness Communication Plan on 01/16/19 at 1:30 PM failed to reflect the facility included a primary and alternate means of communication with facility staff, Federal, State, and local emergency management services in the case of an emergent event.

In an interview on 01/16/19 at 3:21 PM, the Emergency Coordinator stated, "the primary method of communication for staff would be cell phones - but there was nothing identified in the Communication Plan."

Based on interview and review of the facility's Emergency Preparedness Plan (EPP) Communication Plan (CP), the facility failed to identify how the facility would share patient information with other health providers in the event of an emergency to ensure continuity of care. This failure had the potential to affect the seven patients receiving care in the facility and would hinder the facility's ability to provide care to patients during an emergency.

Findings Include:

Review of the facility EPP Communication Plan on 01/16/19 at 1:30 PM did not reveal a method for the sharing of information and medical documentation for the facility's patients with other health care providers to ensure continuity of care.

In an interview on 01/16/19 at 2:50 PM, the Chief Financial Officer (CFO) stated there were methods the facility could use that included the capability of accessing the server from home, a battery backup, and pulling the server hard drive and going to another hospital which had the same computer system - but the alternative methods were not documented in the facility's Communication Plan. In an interview on 01/17/19 at 11:07 AM, the CFO stated inpatient and swing bed patient records were printed, however, that method was not identified in the Communication Plan.