Expired Emergency Operations Agreement
Penalty
Summary
The facility failed to maintain an up-to-date Emergency Operations Plan (EOP) as required by federal regulations. During a record review and interview with the Administrator, surveyors found that the memorandum of understanding with partner facilities and providers, which is necessary to ensure the continuity of services to residents in the event of limitations or cessation of operations, was expired. The agreement provided by the facility had an expiration date in February 2025, and at the time of the survey, it was no longer valid. The Administrator confirmed during the interview that the agreement was expired and stated that renewal was in process. This lapse in maintaining a current arrangement with other facilities could affect the facility's ability to properly respond during an emergency, as required by the emergency preparedness regulations. No specific residents or medical histories were mentioned in relation to this deficiency.
Plan Of Correction
Sierra View Medical Center Distinct Part Skilled Nursing Unit submits this plan of correction as part of the requirement under the State and Federal regulations. The plan of correction is submitted and shall not be construed as admission to the alleged deficiency cited or any liability. The plan of correction shall constitute a credible allegation of compliance. Potential Patients affected The organization was unable to find in a retrospective review that any patients had been adversely affected and were not placed in an immediate jeopardy situation. Immediate Organizational Action During document review, it was noted that the Hospital's Memorandum of Understanding (MOU) with its regional partners had expired on February 26, 2025. The MOU is normally updated by the EMS Coordinator-Disaster Services Fresno County MHOAC and sent out for all parties to agree upon. The Environment of Care/Safety & Security Manager from Sierra View notified the coalition of the need for an updated MOU. The EMS Coordinator from Fresno County then submitted an addendum to the coalition for an extension of the MOU until December 31, 2025. All parties agreed and the amendment to the MOU was officially updated. (Please see attachments A & B highlighted areas) Organizational System Improvements: Persons responsible: Environment of Care/Safety & Security Manager The Environment of Care/Safety & Security Manager will attend regular meetings with the coalition to ensure the MOU does not lapse. PI Monitoring: The MOU will be presented no less than annually to the organization’s Safety Committee for tracking purposes.