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E0034
B

Deficiency in Emergency Preparedness Communication Plan

Flourtown, Pennsylvania Survey Completed on 05-01-2025

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 May 1, 2025, at 8:15 a.m. During an exit interview with the Maintenance Director on the same day at 10:30 a.m., it was confirmed that the documentation necessary to meet this requirement was lacking. This oversight affects the entire facility, as the communication plan is a critical component of emergency preparedness and response.

Plan Of Correction

The facility's emergency preparedness communication plan will include a developed means of providing information about the LTC needs and its ability to help the authority having jurisdiction, the Incident Command Center, or designee. The facility will update the EP Book and add it to QAPI for review.

See complete original report
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