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Based on staff interview, and review of the facility's "Emergency Preparedness" plan, the facility failed to re-evaluate its "Emergency Preparedness" plan on an annual basis. This failed practice had the potential to affect patients admitted to the hospital at the time of a disaster or emergency event. The facility reported patient census of 18 patients at the time of the survey.

Findings include:

Review of the facility's "Emergency Preparedness" plan, with review date of March 2015, indicated the plan had not been reviewed or updated since March 2015.

During an interview on 04/17/2018 at 2:45 PM, when asked about the development and maintenance of the "Emergency Preparedness" plan, the Project Manager for Accreditation and Regulatory Preparedness (Staff 1) stated that he/she was responsible for the plan and the plan had not been reviewed or updated annually.

Review of the facility's "Policy No. HS. 4.1" titled, "HEALTH & SAFETY POLICY," revised March 2015, indicated: "SUBJECT: Emergency Management Plan . . . [section] R. Annual Evaluation, ...The Director of the [sic] Emergency preparedness is responsible for performing [an] annual evaluation of the Emergency Preparedness Program . . . the annual review examines the objectives, scope, performance, and effectiveness of the Emergency Preparedness Program . . . deficiencies are evaluated to set short and long term [sic] goals."

Based on staff interview and facility policy review , the facility failed to ensure a provision for subsistence needs for sewage and waste disposal was included in its "Emergency Preparedness" policy and procedure. This failed practice had the potential to cause patients to be exposed to infection during a disaster or emergency event. The facility reported patient census of 18 patients at the time of the survey.


Findings include:

A review of the facility's "Emergency Preparedness" policy and procedure, dated March 2015, indicated it did not include a policy or procedure for sewage and waste disposal.

During an interview on 04/17/2018 at 2:45 PM, when asked about the development and maintenance of the sewage and disposal of waste, the Project Manager for Accreditation and Regulatory Preparedness (Staff 1) stated, "No, there is no policy or procedure for sewage and waste disposal."

During an interview on 04/18/2018 at 7:30 AM, Staff 1 confirmed no policy was found for sewage and waste disposal as part of the facility's "Emergency Preparedness" plan.

Based on staff interview and facility policy review, the facility failed to ensure the inclusion of a system that preserves patient information and protects its confidentiality in its "Emergency Preparedness" plan. This failed practice had the potential to lead to the loss and/or exposure of confidential patient medical information during a disaster or emergency event. The facility reported patient census of 18 patients at the time of the survey.


Findings include:

A review of the facility's "Emergency Preparedness" plan, dated March 2015, indicated the plan did not include a policy and procedure for preserving and maintaining the confidentiality of patient information during a disaster or
emergency event.

During an interview on 04/17/2018 at 2:45 PM, when asked about the development and maintenance of a system or policy and procedure to ensure the preservation and confidentiality of patient information, the Project Manager for Accreditation and Regulatory Preparedness ( Staff 1) stated, "No, there is no policy or procedure for patient information and confidentiality."

During an interview on 04/18/2018 at 7:30 AM, Staff 1 confirmed no policy and procedure was found for patient information and confidentiality as part of the facility's "Emergency Preparedness" plan.

Based on staff interview and facility policy review, the facility failed to update the communication
plan for its "Emergency Preparedness" plan. This failed practice had the potential to effect patients by potentially hampering the coordination of patient care throughout the hospital system and with emergency management agencies during a disaster or emergency event. The facility reported patient census of 18 patients at the time of the survey.


Findings include:

A review of the facility's "Emergency Preparedness" plan, dated March 2015, indicated the plan included outdated information related to the facility's communication plan during a disaster or emergency event.

During an interview on 04/17/2018 at 2:45 PM, when asked about the development and maintenance of a written communication plan as part of the facility's "Emergency Preparedness" plan, the Project Manager for Accreditation and Regulatory Preparedness (Staff 1) stated the facility uses the WENS (wireless emergency notification system) for communication during an emergency event or disaster. When asked about the location of that information in the facility's "Emergency Preparedness" plan, Staff 1 stated it was not included in the plan because the plan had not been updated annually.

Review of the facility's "Policy No. HS. 4.1" titled, "HEALTH & SAFETY POLICY," revised date "March 2015, indicated: "SUBJECT: Emergency Management Plan ...4. Process of Emergency Management Plan ...M. ...communication systems are available for use during emergency responses. The systems include the regular phone system, public telephones, two-way radios, and cellular phones ..."