Missing Documentation of Emergency Transfer Arrangements
Penalty
Summary
The facility failed to maintain an Emergency Operations Plan (EOP) that included required documentation of arrangements with other facilities or providers to receive residents in the event of limitations or cessation of operations. During a record review and interview with the Safety Director, surveyors found that the facility could not provide evidence of such agreements or arrangements as mandated by federal regulations. The Safety Director stated that there was an agreement with the county, but was unable to produce any documentation to support this claim. This lack of documented arrangements was identified during the review of the EOP and confirmed in the interview, resulting in a deficiency related to emergency preparedness and continuity of care for residents.
Plan Of Correction
Immediate Corrections: The Emergency Management binder and missing documentation were located and returned to the AHDL site. See attached Kern County Emergency Operation Manual, ADHL KCHCC Partner Participation Agreement, and the AH Delano Grant Letter. All residents had the potential to be affected by this issue, but no harm was identified for any residents. Sustainment: The Accreditation Manager educated the Facilities Manager on the requirement to maintain the Emergency Operations Manual on site at all times, and to not allow the binder to be removed for any reason, even short term use. Likewise, the Emergency Management Manager was also educated to complete any updates or changes to the manual on site, and not to take it to another location to work on it. Monitoring: The Manager of Facilities will verify the binder is in the unit at least monthly to ensure that the Manual is still on site and has not been removed. This will continue for 6 months to ensure sustainment. Data will be reported out to the SCU Quality Assurance Committee as part of the QAPI program. Person Responsible: Facilities Manager E 025