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Based on document review and staff interview the hospital failed to provide evidence the Emergency Preparedness Plan had been reviewed and updated annually (refer to E0004), failed to develop the Emergency Preparedness Plan (EPP) based on a facility and community-based all hazards risk assessment and failed to review the plan annually (refer to E0006), failed to review the Emergency Preparedness Communication plan annually (refer to E029), failed to provide training and testing of the Emergency Preparedness Plan (refer to E0036), failed to provide evidence of staff training upon hire and annually (refer to E0037), and failed to provide evidence of testing and analysis of the Emergency Preparedness Plan (refer to E0039).

The cumulative effect of the hospitals failure to have a complete EPP that is reviewed annually, that is based on a facility and community-based all hazards risk assessment, a communication plan that is reviewed and updated annually, and the hospitals failure to include testing, training, and analysis of the EPP places all hospital staff and the community health care system at risk for not knowing what to do or how to respond during an emergency, disaster or hazardous situation putting all patients and the community at risk for unsafe care and service during an emergency.

Based on document review and staff interview the hospital failed to provide evidence the Emergency Preparedness Plan had been reviewed and updated annually. Failure to review and update the Emergency Preparedness Plan places staff, health care community, patients and potential patients at risk for unsafe care and services during an emergency, disaster or hazardous situation.

Review of a document titled "Emergency Operations Plan" with a revised date of 07/2015 showed the plan lacked evidence of an annual review and update.

During an interview on 08/07/18 at 9:15 AM Staff A, Chief Executive Officer (CEO), stated that they recently assigned someone new to be in charge of the emergency preparedness program. Staff A stated that they were working on their emergency preparedness program and know that they have not met all the requirements yet.

Based on document review and staff interview the hospital failed to develop the Emergency Preparedness Plan (EPP) based on a facility-based and community-based all hazards risk assessment and failed to review the plan annually. Failure to develop the EPP based on an all hazards risk assessment and review the plan annually places all patients at risk for unsafe care and services during an emergency, disaster, or hazardous situation.

Findings Include:

Review of a document titled "Emergency Operations Plan" with a revised date of 07/2015 showed the plan lacked evidence that it was based on a facility-based and community-based all hazards risk assessment and lacked evidence the plan was reviewed and updated annually.

During an interview on 08/07/18 at 9:15 AM Staff A, Chief Executive Officer (CEO), stated that they recently assigned someone new to be in charge of the Emergency Preparedness program. Staff A stated that they were working on their Emergency Preparedness program and know that they have not met all the requirements yet.

During an interview on 08/07/18 at 2:00 PM, Staff B, Emergency Preparedness Plan (EPP) and Infection Control Officer, stated that she was just recently assigned Emergency Preparedness and to her knowledge there has not been a risk assessment completed.

Based on document review and staff interview the hospital failed to provide evidence of Emergency Communication training for staff and failed to provide evidence the Emergency Communication plan was reviewed annually. Failure to provide education and training for staff and review and update the Emergency Communication Plan places patients and potential patients at risk for unsafe care and services during an emergency, disaster or hazardous situation.

Findings Include:

Review of a document titled "Emergency Operations Plan" with a revised date of 07/2015 showed the plan lacked evidence of training and annual review of the Emergency Communication plan.

During an interview on 08/07/18 at 9:15 AM Staff A, Chief Executive Officer (CEO), stated that they recently assigned someone new to be in charge of the emergency preparedness program. Staff A stated that they were working on their emergency preparedness program and know that they have not met all the requirements yet.

During an interview on 08/07/18 at 2:00 PM, Staff B, Emergency Preparedness Plan (EPP) and Infection Control Officer, stated there is a call list, but she does not have a communication plan that she is able to provide for review.

Based on document review and staff interview the hospital's failed to provide evidence of a training and testing program for the Emergency Preparedness Plan. Failure to develop a plan for testing, training and annual review of the Emergency Preparedness Plan places all hospital staff and the community health care system at risk for not knowing what to do or how to respond during an emergency, disaster or hazardous situation putting all patients and potential patients at risk for unsafe care and service during an emergency.

Findings Include:

Review of a document titled "Emergency Operations Plan" with a revised date of 07/2015 showed the plan lacked evidence of a training and testing program and lacked evidence the plan was updated annually.

During an interview on 08/07/18 at 9:15 AM Staff A, Chief Executive Officer (CEO), stated that they recently assigned someone new to be in charge of the emergency preparedness program. Staff A stated that they were working on their emergency preparedness program and know that they have not met all the requirements yet.

During an interview on 08/07/18 at 2:00 PM, Staff B, Emergency Preparedness Plan (EPP) and Infection Control Officer, stated that the hospital has not provided any live emergency preparedness training for hospital staff. Staff B stated she has attended a tabletop exercise with emergency management but did not provide hospital staff with the training yet.

During an interview on 08/07/18 at 12:00 PM in the Emergency Department (ED) staff breakroom, Staff D, ED Supervisor, stated that hospital wide staff have not had any training for situations when the computer, telephone, and internet systems go down. There is a big box of printed forms, so we can hand write on those, but I will honestly say we have not had a drill for anything like this.

Based on document review and staff interview the hospital failed to provide evidence of initial and annual training of the Emergency Preparedness Plan for staff. Failure to provide Emergency Preparedness training to hospital staff places all patients and potential patients at risk for unsafe care and service during an emergency, disaster, or hazardous situation.

Findings Include:

Review of a document titled "Emergency Operations Plan" with a revised date of 07/2015 showed the hospital lacked evidence of initial and annual training for staff.

During an interview on 08/07/18 at 9:15 AM Staff A, Chief Executive Officer (CEO), stated that they recently assigned someone new to be in charge of the Emergency Preparedness program. Staff A stated that they were working on their emergency preparedness program and know that they have not met all the requirements yet.

During an interview on 08/07/18 at 2:00 PM, Staff B, Emergency Preparedness Program (EPP) and Infection Control Officer, stated that the hospital has not provided any live emergency preparedness training for hospital staff. Staff B stated she has attended a tabletop exercise with emergency management but did not provide hospital staff with the training yet.

During an interview on 08/07/18 at 12:00 PM in the Emergency Department (ED) staff breakroom, Staff D, ED Supervisor, stated that hospital wide staff have not had any training for situations when the computer, telephone, and internet systems go down. There is a big box of printed forms, so we can hand write on those, but I will honestly say we have not had a drill for anything like this.

Based on document review and staff interview the hospital failed to provide evidence of an annual analysis of the Emergency Preparedness Plan (EPP). Failure to analyze the EPP effectiveness places all staff at risk for being unprepared to provide safe and effective care to patients during an emergency, disaster or hazardous situation.

Findings Include:

Review of a document titled "Emergency Operations Plan" with a revised date of 07/2015 showed the hospital failed to provide evidence of exercises to test and analyze the Emergency Preparedness Plan.

During an interview on 08/07/18 at 9:15 AM Staff A, Chief Executive Officer (CEO), stated that they recently assigned someone new to be in charge of the Emergency Preparedness program. Staff A stated that they were working on their emergency preparedness program and know that they have not met all the requirements yet.

During an interview on 08/07/18 at 2:00 PM, Staff B, EPP and Infection Control Officer, stated that the hospital has not provided any live emergency preparedness training for hospital staff. Staff B stated she has attended a tabletop exercise with emergency management but did not provide hospital staff with the training yet.