Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on February 10, 2026, Penn Highlands Elk - Johnsonburg, was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the following requirements of of 42 CFR, Part 491.12, Subpart A, Conditions for Certification: Rural Health Clinics - Emergency Preparedness.
Plan of Correction:
491.12(e) STANDARD
Integrated EP Program
Name - Component - 00
§416.54(e), §418.113(e), §441.184(e), §460.84(e), §482.15(f), §483.73(f), §483.475(e), §484.102(e), §485.68(e), §485.542(f), §485.625(f), §485.727(e), §485.920(e), §486.360(f), §491.12(e), §494.62(e).
(e) [or (f)]Integrated healthcare systems. If a [facility] 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 [facility] 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.
Observations:
Based on document review, policy and procedure review, observartions (OBS) and staff interviews (EMP) it was determined that the facility lacked written documentation verifying the facility participated in the development and implementation; and developed and maintained in a manner that takes into account each separately certified facility's unique circumstances of the integrated health care system Emergency Preparedness Plan; the facility failed to provide documentation verifying that the facility fully participated in the development, assessment and implementation of the integrated health care system Emergency Preparedness Plan for one (1) of one (1) plans reviewed and two (2) of two (2) observations. (OBS#1 and OBS#2)
Findings include:
OBS#1 on 2/9/26 at approximately 9:30 am revealed: "Domtar Corporation: Johnsonburg Mill" - actively operating paper factory located directly behind facility building approximately 50 yards.
OBS#2 on 2/9/26 at approximately 09:35 am revealed: Active railroad tracks with railway cars incoming and outgoing to afformentioned paper factory lying approximately 20 yards from entrance of facility.
Review of Policy and Procedure on 2/9/26 at approximately 10:00 am revealed:
"Penn Highlands Healthcare, PH Elk... Title: Non-Medical Emergency Procedures... Purpose: To define guidelines for non-medical emergencies in the Medical Practices... Policy: ... the ultimate responsibility for safety in each department rests with the manager or director of each Penn Highlands Medical Practice. In the event of a non-medial emergency... each office staff is responsible for developing a plan within their own area for the ultimate safe evacuation of the office patients and staff..."
Document review on 2/9/26 at approximately 1:00 pm revealed:
"Penn Highlands Johnsonburg Rural Health Center Hazard Vulnerability Assessment Tool review" revealed: "Level/probability score for disasters... likelihood this will occur... score 0 (zero) = N/A; 1 (one) = low; 2 (two) = Moderate; 3 (three) = high... Active Shooter score/probabilityd = 1 (one); Fire score/probability = 1 (one) and Tornado score/probabilty = 0 (zero)... Inclement Weather score/probability = 3 (three); Temperature Extremes score/vulnerability = 3 (three)" Review of Emergency drills documentation conducted by facility revealed: Fire, Active shooter and Tornado drills performed by facility for years 2026, 2025, 2024, 2023, 2022 and 2021.
Interview with the facility regional director (EMP1) and the facility manager (EMP2) on 2/9/26 at approximately 3:00 p.m. revealed that the facility participates in a healthcare system unified education module for an emergency preparedness program and confirmed the facility lacked written documentation verifying that the facility responsible staff fully participated in the development and implementation of the integrated health care system Emergency Preparedness Plan for unique facility situations that are possible non-medical emergencies.
Interview with the facility regional director (EMP1) and the facility manager (EMP2) on 2/9/26 confirmed above findings. EMP1 states "We could do better and do not have those particular situations incorporated into the hazard vulnerability assessment tool."
Plan of Correction:1. The Rural Health Center (RHC) Administrator is responsible for the completion of this plan of correction.
2. The RHC Administrator, Regional Manager and Emergency Preparedness clinic Director will update the HVA and Emergency operating plan within thirty (30) days, by March 27th, 2026, to be specific to the Johnsonburg location.
a. The HVA and Emergency operating plan will be reviewed with the clinic staff within thirty (30) days of completion.
b. The HVA will be maintained biennially by emergency preparedness clinic director, clinic manager and RHC administrator, with a final review conducted with clinic staff. This will ensure that the emergency drills and clinics emergency operating plan are tailored to the clinic's highest vulnerabilities, clinic circumstances, patient population and services the clinic offers. Clinic staff will have the ability to participate in emergency preparedness program during the biennial meeting.
c. The HVA and Emergency Operations Plan will be reviewed annually with policy review.
3. Tabletop and community-based drills will continue to be conducted annually to support and demonstrate the effectiveness of the emergency program. This is documented in an after-action report.
4. Non-medical emergency policy will be revised to align with emergency preparedness requirements.
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed February 10, 2026, Penn Highlands Elk - Johnsonburg, was found to be in compliance with the requirements of 42 CFR, Part 405, Subpart X and 42 CFR, Part 491.1 - 491.12, Subpart A Conditions for Certification: Rural Health Clinics.
Plan of Correction:
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