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E0034
B

Deficiency in Emergency Preparedness Communication Plan

Newtown Square, Pennsylvania Survey Completed on 01-13-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility's emergency preparedness communication plan was found to be deficient as it did not include a means of providing information about the Ambulatory Surgical Center's (ASC) needs and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. This deficiency was identified during a document review conducted on January 13, 2025, at 8:00 a.m. During an exit interview with the Administrator and the Maintenance Director on the same day at 10:30 a.m., it was confirmed that the facility lacked the necessary documentation in its emergency preparedness communication plan. This oversight affects the entire facility, as it fails to comply with the requirement to maintain a comprehensive communication plan that includes the ASC's needs and capabilities.

Plan Of Correction

Facility established policy to provide information about the community's occupancy, needs and its ability to provide assistance, to authorities having jurisdiction. 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.

See complete original report
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