Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on 5/21/2021, Saint Vincent Medical Group was found to have the following standard level deficiencies that were determined to be in substantial compliance with the following requirement(s) of 42 CFR, Part 491.12, Subpart A, Conditions for Certification: Rural Health Clinics - Emergency Preparedness.
Plan of Correction:
491.12(a)(4) STANDARD
Local, State, Tribal Collaboration Process
Name - Component - 00
§403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4)
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:]
(4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. *
* [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency.
Observations:
Based on a review of the agency Emergency Preparedness Plan (EPP) and staff (EMP) interview, the agency failed to ensure the EPP included documentation of the agency efforts to contact, cooperate, and collaborate with emergency preparedness officials (local, tribal, regional, state, federal) in order to facilitate an integrated response during a disaster situation.
Findings Included:
Review of agency EPP completed on 5/21/2021 at approximately 1:00 p.m. revealed Agency EPP failed to contain documentation of collaboration with local, regional, State and Federal EP officals in order to facilitate an integrated response during a disaster situation.
Interview completed on 5/21/2021 at approximately 2:00 p.m. with EMP1, EMP2 & EMP3 confirmed the above findings.
Plan of Correction:The RHC will collaborate emergency preparedness officials.
This will be completed by the office manager via outreach.
The EPP will be shared with the local Fire and Chief Police.
This will be shared every 2 years and documentation or earlier if needing significant updates.
The RHC Manager "or designee" is responsible for the completion of this action.
Every 2 years with an expected 100% compliance, an audit will occur to ensure this action was completed by the office of compliance or regulatory.
Findings will be reported at the program evaluation review every 2 years.
491.12(c) STANDARD
Development of Communication Plan
Name - Component - 00
§403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c).
(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities].
Observations:
Based on a review of the agency Emergency Preparedness Plan (EPP) and staff (EMP) interview, the agency failed to ensure the EPP included a written communication plan that addressed how the agency would interact and coordinate patient care with other healthcare providers, state and local public health departments, and emergency management agencies and systems in the event of a disaster.
Findings Included:
Review of agency EPP completed on 5/21/2021 at approximately 1:00 p.m. revealed the agency EPP failed to include a written communication plan that addressed how the agency would interact and coordinate patient care with other healthcare providers, state and local public health departments, and emergency management agencies and systems in the event of a disaster.
Interview completed on 5/21/2021 at approximately 2:00 p.m. with EMP1, EMP2 and EMP3 confirmed the above findings.
Plan of Correction:The RHC will develop a communication plan as part of the EPP.
The EPP will be updated and reviewed every 2 years.
The RHC Manager "or designee" will reach out to obtain agreements with healthcare providers. These agreements will assist in the event of an emergency to coordinate patient care.
Information regarding state, public health departments, and emergency management agencies will be added to the EPP.
The Practice Manager is responsible for the completion of this action.
Every 2 years, an audit will occur to ensure this action was completed by the office of compliance or regulatory, with an expectation of 100% compliance.
Findings will be reported at the program evaluation review every 2 years.
491.12(c)(5) STANDARD
Information on Occupancy/Needs
Name - Component - 00
§403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7).
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:
(7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
*[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
*[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
Observations:
Based on a review of the agency Emergency Preparedness Plan (EPP) and staff (EMP) interview, the agency failed to establish and maintain an emergency preparedness communication plan that included a method for sharing of information about the agency's needs and ability to provide assistance to the authority having jurisdiction during an emergency event.
Findings included:
Review of agency EPP completed on 5/21/2021 at approximately 1:00 p.m. revealed no evidence of a communication plan that included sharing information about the agency's need and ability to provide assistance during an emergency event.
Interview completed on 5/21/2021 at approximately 2:00 p.m. with EMP1, EMP2 & EMP3 confirmed the above findings.
Plan of Correction:The RHC will develop a communication plan as part of the EPP that specifies their abilities to provide assistance.
The RHC Manager "or designee" is responsible for the completion of this action.
Every 2 years, an audit will occur to ensure this action was completed by the office of compliance or regulatory, with an expectation of 100% compliance.
Findings will be reported at the program evaluation review every 2 years.
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed 5/21/2021, Saint Vincent Medical Group 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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