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Based on written document review and staff interview, the facility failed to develop Emergency Preparedness policies and procedures to address alternate sources of energy to maintain temperatures to protect patient health and safety . This deficient practice affects all staff, visitors and patients.

The findings included:

On 06/06/18 between 9:00 AM and 4:00 PM, review of the written facility emergency plan and policy was conducted with the administrator. The facility was not able to produce the requested written documentation of the procedures. Based on the provided emergency plan, it could not be verified that the facility had included policies and procedures for alternate sources of energy to maintain the temperatures to protect patient health and safety. No written specific policy or procedure was in the actual policy reviewed with the administrator. The written documentation for the required facility federal emergency plan and policy to meet code requirements was not available in the plan at the time reviewed and when requested to produce requested written documentation to substantiate compliance. An interview was conducted at this time with the administrator who acknowledged that the documentation requested was not available in the facility emergency plan.

The findings were acknowledged by and verified by the administrator at the time of documentation review and at the exit conference on 06/06/18.

Actual code requirements:
CFR 482.15