Initial Comments:
A recertification survey was conducted October 25 and 26, 2022, to determine compliance with the requirements of 42 CFR Part 485, Subpart J Requirements for Community Mental Health Centers. The sample consisted of six individuals. There were no deficiencies.
Plan of Correction:
Initial Comments:
A recertification survey was conducted October 25 - 26, 2022, to determine compliance with the requirements of 42 CFR Part 485, Subpart J Requirements for Emergency Preparedness in Community Mental Health Centers. The sample consisted of six individuals.
Plan of Correction:
485.920(a)(1)-(2) STANDARD
Plan Based on All Hazards Risk Assessment
Name - Component - 00
§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:]
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*
(2) Include strategies for addressing emergency events identified by the risk assessment.
* [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.
*[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.
*[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.
Observations:
Based on facility documentation and interview, it was determined that the facility failed to update an emergency preparedness plan, that was based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. This applied to all the consumers at the facility. Findings included:
Review of facility provided documentation completed on October 26, 2022, revealed that the facility's current emergency operations plan was completed in 2019. This review further revealed that the facility failed to maintain and update a comprehensive emergency preparedness plan that was based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. Further review failed to reveal that the plan was reviewed and updated at least every two years.
Interview with the safety officer/facilities director and the compliance officer on October 26, 2022, at 11:00 AM, confirmed that the facility's emergency preparedness plan has not been updated since 2019, and was developed without an updated comprehensive all hazards approach risk assessment.
Plan of Correction:Safety Officer, who is responsible for developing and reviewing the emergency operations plan, has been trained on the requirements of the risk assessment and the emergency operations plan as of 11/18/22.
A documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, will be completed by the safety officer by 12/23/22.
The emergency preparedness plan will be updated based on the risk assessment by 1/1/23.
The emergency operations plan, including the risk assessment, will be reviewed and updated as needed by the safety officer at minimum every 2 years.
Compliance Officer will add the updating of the emergency operations plan to the annual Compliance Monitoring Plan for Safety and Facilities to ensure ongoing compliance.
485.920(d) STANDARD
EP Training and Testing
Name - Component - 00
§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).
*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] 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 every 2 years.
*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility 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.
*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID 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 every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).
*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation 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, testing and orientation program must be evaluated and updated at every 2 years.
Observations:
Based on a review of facility emergency preparedness documentation and interview, it was determined that the facility failed to provide training to all staff regarding the emergency preparedness policy and procedures at least every two years. This applied to five of 11 staff at the facility. Findings included:
A review of the facility's emergency preparedness documents were completed on October 26, 2022. This review failed to reveal training documentation for five staff on the emergency preparedness policy and procedures every two years.
Interview with the safety officer/facilities director and compliance officer on October 26, 2022, at 11:00 AM confirmed the facility had no documentation that these five staff were trained at least every two years in the emergency preparedness policy and procedures.
Plan of Correction:Beginning 1/1/23, all new hires will be assigned emergency preparedness policy and procedures training upon hire.
Additionally, all current staff will receive emergency preparedness policy and procedure training by 1/16/23.
Trainings will continue to be assigned at hire and every 2 years thereafter, to coincide with the same year that the emergency operations plan is updated.
Completion of required trainings will be included on the annual Compliance Monitoring Plan for Safety and Facilities to ensure ongoing compliance.
Compliance Officer will audit on 1/16/23 to ensure all current staff have received training and documentation is in HR files.
Compliance Officer will continue to audit every 2 years to ensure compliance of biannual trainings.
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