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GREELEY COUNTY HEALTH SERVICES
Develop EP Plan, Review and Update Annually
Tag No.: E0004
Based on interview and review of facility documentation, it was determined the facility failed to develop and maintain an emergency preparedness plan and update the plan on an annual basis. This failure could possibly delay staff response time during an emergency and has the potential to affect all patients receiving treatment in the hospital.
Findings include:
On 07/12/18 at 10:00 AM, an interview was conducted with the Maintenance/Plant Services Director (PSD). The PSD stated the facility's Emergency Operations Plan (EOP) had not been updated since August 2016. In addition, the PSD stated the EOP was not reviewed and updated on an annual basis.
Review of facility's documentation titled, "Emergency Operations Plan," dated 08/2016, indicated no evidence the EOP was reviewed on an annual basis. In addition, review of the EOP revealed the plan did not contain evidence the plan had approval signatures.
On 07/12/18 at 10:20 AM, an interview was conducted with the Chief Executive Officer (CEO). The CEO stated the facility had been working on updating the policies related to the EOP, but had not had anything approved. In addition, the CEO acknowledged the EOP had not been maintained and reviewed on an annual basis.
Plan Based on All Hazards Risk Assessment
Tag No.: E0006
Based on interview and review of facility documentation, it was determined the facility failed to ensure the emergency preparedness plan included a documented, facility-based and community-based risk assessment. This failure potentially affects all patients receiving care in the hospital and hinders the hospital's ability to accurately identify potential emergency situations and develop strategies to keep patients safe during an emergency event.
Findings include:
On 07/12/18 at 10:00 AM, an interview was conducted with the Maintenance/Plant Services Director (PSD). The PSD stated the facility's Emergency Operations Plan (EOP) did not include a facility based or community based risk assessment. Although the PSD did indicate the facility has strategies in place to respond to various emergency events. The PSD stated the facility did not utilize an assessment to develop strategies for emergency situations.
Review of facility's documentation titled, "Emergency Operations Plan," dated 08/2016, indicated no evidence the EOP included a facility based risk assessment or a community based risk assessment. The review of the EOP further revealed the facility had not developed any strategies based on the use of a risk assessment.
On 07/12/18 at 10:20 AM, an interview was conducted with the Chief Executive Officer (CEO). The CEO stated the facility had been working on updating the policies related to the EOP. However, the CEO acknowledged the facility had not completed a facility based risk assessment and had not included a community based risk assessment in developing or maintaining the EOP.