HospitalInspections.org

Based on review of policies and procedures and staff interview, the CAH (Critical Access Hospital) failed to develop a disaster plan that included sewer system failure. Census on the first day of the survey was 4 swing bed patients. The Critical Access Hospital Annual Evaluation (dated 6/24/14), identified that the facility had a total of 137 acute inpatients and 72 swing bed patients from 5/1/13 through 4/30/14. The lack of a plan for sewer system failure has the potential to affect all patients of the CAH.

Findings are:

A. A review of the the Utility Management Plan (dated 7/21/14) revealed the following information: "The UMS [Utility Management System] shall provide for emergency processes for utility systems failures or disruptions. Refer to [name of the CAH] Emergency Management Plan."

A review of the [Name of the CAH] Emergency Management Plan revealed the following information: "By implementing this plan, [name of the CAH] will achieve the following objectives....Provide alternative sources of essential utilities."

A review of the facility's entire disaster preparedness manual revealed no plan for sewer system failure.

B. Interview with the CEO (Chief Executive Officer) on 8/7/14 at 10:40 AM, confirmed the lack of a plan in the event of a sewer system failure.