| 403.748(b)(2), 416.54(b)(1), 418.113(b)(6)(ii) and (v), 441.184(b)(2), 482.15(b)(2), 483.475(b)(2), 483.73(b)(2), 485.542(b)(2), 485.625(b)(2), 485.920(b)(1), 486.360(b)(1), 494.62(b)(1) STANDARD Procedures for Tracking of Staff and Patients: |  |
§403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1).
[(b) Policies and procedures. The [facilities] must develop and implement 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 every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]
[(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility'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.
*[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF's, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF's, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location.
*[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures.
(ii) Safe evacuation from the hospice, 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.
(v) A system to track the location of hospice employees' on-duty and sheltered patients in the hospice's care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location.
*[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, 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.
*[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.
*[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients.
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Observations:
Name: - Component: -- - Tag: 0018
Based on document review and interview, it was determined the facility failed to develop Policies and Procedures to include tracking of residents and staff during an emergency, as part of the Emergency Preparedness plan, affecting the entire facility.
Findings include:
1. Document review on February 6, 2026, at 8:15 am, revealed the Facility's Emergency Preparedness Plan did not include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location if on-duty staff and sheltered patients are relocated during an emergency.
Exit interview with the Administrator and the Maintenance Director on February 6, 2026, at 11:00 am, confirmed the lack of documentation.
| | Plan of Correction - To be completed: 04/01/2026
1. What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored:
The facility will ensure that the Emergency Preparedness Plan will include Procedures for Tracking of Staff and Residents during an emergency. The policy will include tracking the location of staff on duty and residents in the facility during an emergency. If staff on duty and residents are relocated during an emergency, the facility will document the specific name and location of the receiving facility or location. This policy Tracking of Staff will be reviewed and updated every two years.
The Maintenance Director or designee will educate the Mechanics and Facility Staff on the Tracking of Staff and Residents during an emergency Policy & Procedures.
2.What quality assurance program will be put into place, and the dates when corrective action will be completed:
The Maintenance Director or designee will conduct an audit for two months to ensure that the Emergency Preparedness Plan which includes the Tracking of Staff and Residents Policy and Procedures during an emergency has been implemented and reviewed. Completed audits will be reviewed at Quarterly QAPI meeting for and further recommendations.
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