Deficiency in Emergency Preparedness Documentation
Penalty
Summary
The facility was found to be deficient in developing and implementing emergency preparedness policies and procedures that include a system of medical documentation. This system is required to preserve patient information, protect the confidentiality of patient information, and secure and maintain the availability of records. During a document review conducted on January 13, 2025, it was revealed that the facility failed to establish such a system, affecting the entire facility. An exit interview with the Administrator and the Maintenance Director confirmed the lack of documentation. This deficiency indicates that the facility did not comply with the regulatory requirements for emergency preparedness, specifically in maintaining a system that ensures the protection and availability of patient records. The absence of these policies and procedures could potentially impact the facility's ability to manage patient information effectively during emergencies.
Plan Of Correction
Facility established a policy for protection of privacy with appropriate users and disclosures of protected Health information during an emergency. The Senior Director of Property and Facilities will ensure the Emergency Operations Manual and related policies are reviewed on an annual basis. Results of review will be submitted by The Senior Director of Property and Facilities to the Quality Assurance and Performance Improvement Committee on an annual basis.