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Based on record review and interview the facility failed to provide documentation showing the hospital complies with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. (Refer to E-0004- K-0100)

Based on record review and interview the facility failed to provide documentation showing the hospital complies with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

The Findings include:

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00 AM revealed the facility could not provide documentation showing the facility maintains an emergency preparedness plan that meets the CMS requirements utilizing an all hazards approach.

Based on record review and interview the facility failed to provide documentation showing the facility maintains and updates the required emergency preparedness plan, based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, and include strategies for addressing emergency events identified by the risk assessment.

The Findings include:

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00 AM revealed the facility could not provide documentation showing the facility maintains and updates an emergency preparedness plan that meets the CMS requirements utilizing an all hazards approach.

Based on record review and interview the facility failed to provide documentation showing the facility address patient/client population, including, but not limited to, persons at-risk; the type of services the hospital has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.

The findings include:

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00 AM revealed the facility could not provide documentation showing the facility patient/client population, including, but not limited to, persons at-risk; the type of services the hospital has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.

Based on record review and interview the facility failed to provide documentation showing the facility established a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts.

The findings include:

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00 AM revealed the facility could not provide documentation showing a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts as required by CMS.

Based on record review and interview the facility failed to provide documentation showing the facility developed and implemented the emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually.

The findings include:

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00AM revealed the facility could not provide documentation showing the policies and procedures for the emergency preparedness plan have been reviewed and updated at least annually as required by CMS.

Based on record review and interview the facility failed to provide documentation showing the facility has policies and procedures for subsistence needs for staff and patients (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following:
(i) Food, water, medical and pharmaceutical supplies
(ii) Alternate sources of energy to maintain the following:
(A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(B) Emergency lighting.
(C) Fire detection, extinguishing, and alarm systems.
(D) Sewage and waste disposal.
The facility currently cannot provide and maintain temperature control in the event of power failure.

The findings include:

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00 AM revealed the facility could not provide documentation showing the facility can provide and maintain temperature control though out the entire building in the event of a power failure. The facility does not have policies and procedures addressing subsistence needs for staff and patients as required by CMS.

Based on record review and interview the facility failed to provide documentation showing the facilities policies and procedures for tracking of staff and patients. A system to track the location of on-duty staff and sheltered patients in the hospital's care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location.

The findings include:

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00 AM revealed the facility could not provide documentation showing the facility has a system to track the location of on-duty staff and sheltered patients in the hospital's care during an emergency as required by CMS.

Based on record review and interview the facility failed to provide documentation showing the facilities policies and procedures for policies and procedures for evacuation. Safe evacuation from the hospital, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance as required by CMS.

The findings include:

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00AM revealed the facility could not provide documentation showing the facilities policies and procedures for evacuation. Safe evacuation from the hospital, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance as required by CMS.

Based on record review and interview the facility failed to provide documentation showing the facilities policies and procedures for sheltering. The hospital must have a means to shelter in place for patients, staff, and volunteers who remain in the hospital.

The findings include:

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00 AM revealed the facility could not provide documentation showing the facilities policies and procedures along with detailed plans to include temperature control when sheltering in place as required in the emergency preparedness plan required by CMS.

Based on record review and interview the facility failed to provide documentation showing the facilities policies and procedures for Medical Documentation. A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

The findings include:

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00 AM revealed the facility could not provide documentation showing the facilities policies and procedures for Medical Documentation in the event of power loss or evacuation as required in the emergency preparedness plan required by CMS.

Based on record review and interview the facility failed to provide documentation showing the facilities policies and procedures for arrangements with other facilities. The development of arrangements with other hospitals and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

The Findings include:

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00 AM revealed the facility could not provide documentation showing the facilities policies and procedures for the arrangements with other hospitals and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients as required in the emergency preparedness plan required by CMS.

Based on record review and interview the facility failed to provide documentation showing the facilities policies and procedures for Roles under a Waiver Declared by Secretary. The role of the hospital under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

The findings include:

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00 AM revealed the facility could not provide documentation showing the facilities policies and procedures for Roles under a Waiver Declared by Secretary. The role of the hospital under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials as required in the emergency preparedness plan required by CMS.

Based on record review and interview the facility failed to provide documentation showing the facilities policies and procedures for the Development of Communication Plan. The hospital must develop and maintain an emergency preparedness (EP) communication plan that complies with Federal, State and Local laws and must be reviewed and updated at least annually.

The Findings include

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00 AM revealed the facility could not provide documentation showing the facilities policies and procedures for the Development of Communication Plan. . The hospital must develop and maintain an emergency preparedness (EP) communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually officials as required in the emergency preparedness plan required by CMS.

Based on record review and interview the facility failed to provide documentation showing the facilities policies and procedures for the list of Names and Contact Information. (c)The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other hospitals
(v) Volunteers.

The findings include:

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00 AM revealed the facility could not provide documentation showing the facilities policies and procedures for the list of Names and Contact Information as required in the emergency preparedness plan required by CMS.

Based on record review and interview the facility failed to provide documentation showing the facilities policies and procedures for the facilities list of Emergency Officials Contact Information. (c)(2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.

The findings include:

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00 AM revealed the facility could not provide documentation showing the facilities list of Emergency Officials Contact Information as required in the emergency preparedness plan required by CMS.

Based on record review and interview the facility failed to provide documentation showing the facilities policies and procedures for Primary/Alternate Means for Communication. (c)(3) Primary and alternate means for communicating with the following:
(i) Hospital staff.
(ii) Federal, State, tribal, regional, and local emergency management agencies.

The findings include:

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00 AM revealed the facility could not provide documentation showing the facilities policies and procedures for Primary/Alternate Means for Communication as required in the emergency preparedness plan required by CMS.

Based on record review and interview the facility failed to provide documentation showing the facilities policies and procedures for Methods for Sharing Information. (c)(4) A method for sharing information and medical documentation for patients under the hospital's care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). (6) A means of providing information about the general condition and location of patients under the hospital's care as permitted under 45 CFR 164.510(b)(4).

The findings include:

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00AM revealed the facility could not provide documentation showing the facilities policies and procedures for Methods for Sharing Information as required in the emergency preparedness plan required by CMS.

Based on record review and interview the facility failed to provide documentation showing the facilities policies and procedures for sharing information on occupancy/needs. (c)(7) A means of providing information about the hospital's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

The findings include:

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00AM revealed the facility could not provide documentation showing the facilities policies and procedures for sharing information on occupancy/needs as required in the emergency preparedness plan required by CMS.

Based on record review and interview the facility failed to provide documentation showing the facilities policies and procedures for Emergency Prep Training and Testing. (d) Training and testing. The hospital must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

The findings include:

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00 AM revealed the facility could not provide documentation showing the facilities policies and procedures for Emergency Prep Training and Testing as required in the emergency preparedness plan required by CMS.

Based on record review and interview the facility failed to provide documentation showing the facilities policies and procedures for Emergency Prep Training Program. (1) Training program. The hospital must do all of the following:(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.

The findings include:

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00 AM revealed the facility could not provide documentation showing the facilities policies and procedures for Emergency Prep Training Program as required in the emergency preparedness plan required by CMS.

Based on record review and interview the facility failed to provide documentation showing the facilities policies and procedures for Emergency Prep Testing Requirements. (2) Testing. The hospital must conduct exercises to test the emergency plan at least annually, including unannounced staff drills using the emergency procedures. The hospital must do all of the following:
(i) Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the hospital experiences an actual natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in a community-based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event:
(ii) Conduct an additional exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based.
(B) A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospital response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.

The findings include:

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00 AM revealed the facility could not provide documentation showing the facilities policies and procedures for Emergency Prep Testing Requirements as required in the emergency preparedness plan required by CMS.

Based on record review and interview the facility failed to provide documentation showing the facilities policies and procedures for Hospital CAH and LTC Emergency Power. (e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section. (1) Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated. (2) Emergency generator inspection and testing. The hospital must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code. (3) Emergency generator fuel. Hospitals that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates.

The findings include:

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00 AM revealed the facility could not provide documentation showing the facilities policies and procedures for Hospital Emergency Power. The facility currently has Operating Rooms, Critical Care Units, Ventilator and Life Support Dependent Patients and an Emergency Department that the facility cannot provide temperature control in the event of a power outage, even if the existing generator turns on. The existing generator is not connected to the HVAC system.

Based on record review and interview the facility failed to provide documentation showing the facilities policies and procedures for Integrated Health Systems. (f) Integrated healthcare systems. If a hospital is part of a healthcare system consisting of multiple separately certified healthcare facilities that elects to have a unified and integrated emergency preparedness program, the hospital may choose to participate in the healthcare system's coordinated emergency preparedness program.
If elected, the unified and integrated emergency preparedness program must- [do all of the following:]
(1) Demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program.
(2) Be developed and maintained in a manner that takes into account each separately certified facility's unique circumstances, patient populations, and services offered.
(3) Demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance [with the program]. (4) Include a unified and integrated emergency plan that meets the requirements of paragraphs (a)(2), (3), and (4) of this section. The unified and integrated emergency plan must also be based on and include the following:
(i) A documented community-based risk assessment, utilizing an all-hazards approach.
(ii) A documented individual facility-based risk assessment for each separately certified facility within the health system, utilizing an all-hazards approach. (5) Include integrated policies and procedures that meet the requirements set forth in paragraph (b) of this section, a coordinated communication plan, and training and testing programs that meet the requirements of paragraphs (c) and (d) of this section, respectively.

The findings include:

Record review and interview with the Administrative staff and the Facilities Maintenance staff on June 6, 2019 at 11:00 AM revealed the facility could not provide documentation showing the facilities policies and procedures for Integrated Health Systems as required in the emergency preparedness plan required by CMS.

Based on observation, interview and record review the facility failed to ensure it can provide temperature control to any area in the building in the event of a power failure including all critical care areas. The existing generator in the building is not connected to the air conditioning system (HVAC).

The findings include:

Observation, interview and record review with the facility Administrative and the Facilities Maintenance staff on June 6, 2019 revealed the facility does not have the capability to maintain or provide temperature control throughout all five stories of the building in the event of a power outage or power failure. The facility has critical care areas such as Operating Rooms, Critical Care units (ICU/CCU), Patients dependent on Life Support or Ventilators and an Emergency Room. It is essential that these areas located on the fifth floor of the building and the emergency room on the ground floor have the capability to maintain and provide temperature control at all times 24 hours a day 365 day a year.