HospitalInspections.org

Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to the Life Safety Code inspection tags: K0321, K0324, K0345, K0346, K0353, K0354, K0761, K0912, K0920 for additional information.

Based on interview and document review, the facility failed to ensure their emergency preparedness plan (EPP) included policies and procedures to address and identify the facility's role 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 during an emergency. This had the potential to affect all patients in the facility.

Findings include:

Upon review of the facility's EPP, Emergency Procedures, dated December 2023, the EPP lacked documentation of or policy addressing the facility's role under an 1135 waiver declared by the Secretary during an emergency.

During an interview on 4/17/24 at 11 a.m., the director of facilities regulations and the director of plant services identified the EPP lacked any information on the facility's role under a waiver declared by the Secretary, in accordance with section 1135 and indicated they did not know of a specific policy or wording in the facilities plan on what the facility would do.

During an interview on 4/17/24 at 12:05 p.m., the director of quality identified the facility did not have a policy regarding the facility's role under a waiver declared by the Secretary, in accordance with section 1135 other than licensing of providers in an emergency.