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Based on interviews and document review, it was determined the facility failed to establish policies or procedures that include all considerations for safe evacuation from the facility, including consideration of the facility's complex patient population, suitable emergency transportation, and identified evacuation locations.

The findings include:

The surveyor conducted interview with Staff Member #9 (Director of Plant Operations) on 05/09/23 at 1:46 pm during review of the facility's Emergency Preparedness program. Staff Member #9 confirmed they were responsible in overseeing the facility's compliance with EP and provided the surveyor with the facility EP binder.

The surveyor was supplied the facility policy titled, "Emergency Operations Plan" (with last revision date of 01/2022) as well as the "Shelter in Place" policy (with last revision date of 07/2022) in the afternoon of 05/09/23. The surveyor located documentation in both policies to address the primary and secondary methods of communication as well as staff role responsibilities and hierarchy.

There was no mention within the Emergency Operations Plan, Shelter in Place policy or other areas of the EP binder to address and delineate evacuation procedures. More specifically, the surveyor was unable to locate information regarding the specific evacuation procedures and locations with consideration for the patient population's complex medical needs and transportation services appropriate for the Long-Term Acute Care Hospital (LTACH) setting within both documents and throughout the EP binder.

The surveyor addressed the concerns with Staff Member #9 during same interview on 05/09/23 at 1:46 pm. Staff Member #9 referenced the expected procedures during a facility fire found in the policy, "Code Fire Emergency/Code Red" (with last revision date of 03/23).

On page five (5) of said policy, the document reads, "Evacuation will be done in the following manner: Evacuate those patients that are most immediately endangered in the fire emergency area; ambulatory next; the wheelchair and bed-ridden patients last".

The surveyor questioned Staff Member #9 whether there was specific information surrounding evacuation guidelines for emergency situations beyond a fire scenario. The surveyor received no response. Additionally, the staff member was unable to identify a designated evacuation location for the patients and staff.

The surveyor conducted an interview with Staff Member #3 on same day to question the availability of emergency transportation services. Staff Member #3 supplied the surveyor with the Transportation Agreement with "Hospital to Home" services, however, there was no mention within the agreement regarding emergency transportation to other facilities beyond the patient's home.

The surveyor addressed the above concerns with Staff Member #1, Staff Member #2, Staff Member #3, Staff Member #14 during exit conference conducted on 05/10/23 at approximately 2:15 pm. Staff present demonstrated understanding of concerns without further questions or concerns.

Based on interview and document review, it was determined the facility failed to establish an effective communication plan with readily available and up to date contact information of emergency personnel.

The findings include:

The surveyor conducted interview with Staff Member #9 (Director of Plant Operations) on 05/09/23 at 1:46 pm during review of the facility's Emergency Preparedness program. Staff Member #9 confirmed they were responsible in overseeing the facility's compliance with EP and provided the surveyor with the facility EP binder.

Following review of the EP binder, the surveyor was unable to identify a communication plan with applicable up to date name and contact information of emergency personnel. The surveyor reviewed the "Emergency Contacts" section located on page two (2) of the facility's "Emergency Operations Plan" (with last revision date of 01/2023).

The surveyor noted that the listed contacts listed on the aforementioned section contained only one (1) of four (4) staff members actively present in facility. The surveyor identified that the Chief Executive Officer, Chief Clinical Officer, and Director of Quality Management mentioned in the emergency contacts documents were no longer employed with the facility.

The surveyor notified both Staff Member #3 and Staff Member #9 during interview in the evening of 05/09/23. Both staff members gave notion to surveyor they were not aware of the outdate contact information, and agreed that such information should be promptly updated and revised.

Additionally, the surveyor was unable to ascertain any mention of contact information any physicians, volunteers (if applicable), hospitals or any other entities that would assist in providing emergency services under prior arrangement.

The surveyor addressed the above concerns with Staff Member #1, Staff Member #2, Staff Member #3, Staff Member #14 during exit conference conducted on 05/10/23 at approximately 2:15 pm. Following notification, the surveyor was supplied a document titled, "Leadership Emergency Call Back" which entailed of a list of facility administrative staff without mention to physicians or hospital(s). Additionally, there was no documentation to indicate the approval date by the Governing Body, Director of Plant Operations or other responsible staff. Facility staff made aware.