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Based on review of the Emergency Preparedness Plan (EPP), supporting documents, and an interview conducted on 01/03/2025, the Hospital failed to comply with the requirements for developing and implementing emergency preparedness policies and procedures as outlined in §482.15(b). Specifically, the facility did not establish clear safeguards for backup generators, including details on their capacity to provide sufficient power to critical areas during power outages. Additionally, there were no detailed policies specifying when, where, or how patient relocation or evacuation would occur if backup power systems failed or became overwhelmed.

The facility ' s emergency preparedness policies lacked any protocols regarding the necessary steps to notify authorities having jurisdiction (AHJ), including the State Surveying Agency and Licensing Agency, upon the activation of the emergency preparedness plan. The failure to notify these authorities in a timely manner in the event of an emergency could result in non-compliance with regulatory requirements and hinder the appropriate response and oversight from relevant agencies.

The regulations require that healthcare facilities include specific procedures not only for backup power systems but also for communicating with regulatory authorities when emergencies arise. The absence of such policies presents a risk that the facility may not meet compliance requirements and may experience delays in the oversight and support necessary for effective emergency response.

Findings Include:

A review of the agency's Emergency Preparedness Program (EPP), last reviewed in 2024, revealed the absence of policies or procedures detailing the safeguards for backup power systems, their operational capacity, and the critical areas of the facility that rely on power during emergencies. Additionally, there were no procedures addressing what should be done if backup power systems fail or are insufficient to meet the needs of the facility. Furthermore, the plan lacked any explicit protocols for when and how to notify authorities having jurisdiction (AHJ), such as the State Surveying Agency and Licensing Agency, upon the activation of the emergency preparedness plan.

The following policies were supplied for review:

Title: 200-EOC Continuity of Operations Plan - UKHSSFC
Policy Number: 200 - EOC
This policy outlines the hospital ' s continuity of operations plan, addressing the protection of essential functions during and after a disaster. It focuses on maintaining operational capabilities despite emergencies and ensuring recovery in cases of prolonged disruption.

Title: 138-EOC Loss of Normal Electrical Power - UKHSSFC
Policy Number: 138 - EOC
This policy describes the steps to take in the event of a loss of normal electrical power, including the activation of emergency backup generators and managing critical systems to ensure patient safety.

Despite these detailed policies, both documents lacked the required sections for notifying the appropriate authorities, such as the State Surveying Agency and Licensing Agency, when the emergency preparedness plan is activated. Additionally, the policies did not contain clear guidelines or protocols for ensuring that essential functions, such as patient relocation or evacuation in case of power failure, would be carried out promptly. There were also no defined timeframes for initiating evacuations or relocations or for informing the authorities regarding the emergency.

During an interview on 01/03/2025, between 3:00 PM and 8:00 PM, the Emergency Operations Manager confirmed that the emergency preparedness policies did not include instructions for notifying the appropriate regulatory agencies, such as the State Surveying Agency and Licensing Agency, when the emergency preparedness plan was activated. The Emergency Operations Manager also acknowledged the lack of documented procedures outlining who would be responsible for initiating patient evacuation or relocation if backup power systems failed.

The Emergency Operations Manager confirmed that these key components were missing from the most recent review of the Emergency Preparedness Program and noted that no formal action had been taken to address these gaps in the facility's preparedness plans. This lack of clear procedures for communication with authorities could result in delays in reporting critical incidents and affect the facility ' s ability to comply with regulatory expectations in an emergency situation.