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Based on document review and staff interview, it was determined that the facility failed to develop and maintain a comprehensive emergency preparedness program.

Findings include:

1. The facility failed to ensure emergency preparedness plans are updated at least annually. Cross reference to Tag E 004.

2. The facility failed to develop an emergency preparedness plan that addresses the specific needs of the patient population. Cross reference Tag E 007.

3. The facility failed to develop an emergency preparedness plan that includes efforts to contact and coordinate emergency plans with the local emergency management office. Cross reference Tag E 009.

4. The facility failed to develop an emergency preparedness plan that includes a system for tracking the location of on-duty staff and the locations of patients. Cross reference Tag E 018.

5. The facility failed to develop an emergency preparedness plan that addresses how volunteers would be used during emergencies. Cross reference Tag E 024.

6. The facility failed to develop an emergency preparedness plan that includes agreements with alternate facilities to receive patients during an emergency. Cross reference Tag E 025.

Based on document review and staff interview, it was determined that the facility failed to ensure emergency plans are reviewed and updated at least annually.

Findings include:

1. During a review of the Emergency Management Plan on 9/5/19, the last review date was documented as 3/9/17.

a. During an interview on 9/5/19 at 11:00 AM, Staff #2 stated the Emergency Management Plan for the hospital has not been reviewed and/or updated in the past two (2) years.

Based on document review and staff interview, it was determined that the facility failed to ensure emergency preparedness plans addressed the patient population.

Findings include:

During a review of the Emergency Management Plan on 9/5/19, the approved plan lacked evidence that precautions were taken to protect behavioral health patents during an evacuation.

1. During a review of the Emergency Management Plan on 9/5/19, the plan did not address the specific patient population.

a. During an interview on 9/5/19 at 11:10 AM, Staff #2 confirmed that a meeting was scheduled with the County Office of Emergency Management in the coming months to discuss this topic but the meeting has not yet occurred and an exact date of the meeting has not yet been finalized.

Based on staff interview, it was determined that the facility failed to document efforts to contact the Local Emergency Management Office to coordinate emergency planning.

Findings include:

1. During an interview on 9/5/19 at 11:45 AM, Staff #2 stated that contact with the local Office of Emergency Management was not made within the previous 2-years.

Based on document review and staff interview, it was determined that the emergency preparedness plan lacks a plan and system for tracking the location of on-duty staff and the locations of patients.

Findings include:

1. During a review of the Emergency Management Plan on 9/5/19, the plan lacked information on the tracking of on-duty staff and the locations of patients.

a. During an interview on 9/5/19 at 11:15 AM, Staff #2 confirmed the Emergency Management Plan does not address the tracking of on-duty staff and the locations of receiving facilities during an evacuation.

Based on document review and staff interview, it was determined that the emergency preparedness plan does not address the use of volunteers during emergencies.

Findings include:

1. During a review of the Emergency Management Plan on 9/5/19, the plan lacked policies and procedures on the use of volunteers during emergencies.

a. During an interview on 9/5/19 at 11:15 AM, Staff #2 confirmed the Emergency Management Plan does not address the use of volunteers during emergencies.

Based on document review and staff interview, it was determined that the facility has not documented and/or obtained agreements with alternate facilities to receive patients during an emergency.

Findings include:

1. During a review of the Emergency Management Plan on 9/5/19, the plan lacked arrangements with alternate facilities to receive patients during an emergency.

a. During an interview on 9/5/19 at 11:15 AM, Staff #2 confirmed the Emergency Management Plan does not include arrangements with alternate facilities to receive patients during an emergency.