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Tag No.: E0026
Based on document review and staff interview it was determined the hospital failed to define their role of the Critical Access Hospital (CAH) under the waiver declared by the Secretary, in accordance with 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.
Findings include:
1. During the facility's emergency preparedness document review conducted on 04/20/21 between the hours of 12:30 p.m. and 1:30 p.m., the facility failed to complete the following emergency preparedness elements:
a. On 04/20/21 at approximately 1:00 p.m., review of policies and procedures regarding the role of the hospice under a waiver declared by the Secretary, in accordance with 1135 of the Act, revealed the provision of care and treatment at an alternate care site was not available for review.
2. Interview on 04/20/21 at approximately 1:31 p.m. with the Director of Nursing, Utilization Review Nurse, and Emergency Management Director verified these findings. The findings were also acknowledged by the Chief Executive Officer at the exit interview on 04/20/21 at approximately 2:00 p.m.