Fmc Pomona

“Development of EP Policies and Procedures CFR(s): §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: 37656 Based on staff interviews and a review of facility documents, it was determined that the facility failed to implement the facility emergency preparedness policies and procedures when one of one back-up generator was identified as no longer functioning longer than expected, an identified medium risk hazard through the facility’s Hazard Vulnerability Assessment (HVA), in the event of power failure that will likely threaten the health or safety of the dialysis patients and staff. Findings include: On 4/30/24 at 10:15 AM, Staff (S)1, Clinic Manager, stated that the facility generator had been inoperable since 4/11/24. S1 stated that their back up plan was to transfer their patients to another facility. The facility’s patient census on 4/30/24 was as follows: in-center hemodialysis - 71, home peritoneal dialysis - 20, and home hemodialysis 2. Per S1, all in-center patients continued to be dialyzed in the facility from 4/11/24 until the day of the survey without a functioning generator. Per S1, a technician from the generator company was scheduled to repair the generator on 5/1/24. S1 confirmed that there was no portable generator. A review of the Quarterly Governing Body Meeting Minutes, dated 4/24/24, stated, “... Generator - not working as of 4/16 [sic] - back up clinic will be ... [Name of Facility] - we are in process of getting it fixed. ...” Per interview with S1 on 4/30/24 at 12:45 PM, the date documented should have been 4/11 instead of 4/16. A review of facility policy titled, “Guidelines for Emergency Preparedness,” published 07/03/23, stated, “... The purpose of this policy is to provide guidelines for emergency preparedness of In-center and Home Therapies facilities to help protect patients and staff in emergency situations. ... Listed below are examples of disasters facilities may encounter ... Bomb threat, Chemical Spill, Power Failure ...” A review of facility policy titled, “Guidelines for Use of Portable Emergency Generators,” published 11/06/23, stated, “... The purpose of this policy is to provide the facility management with a plan for determining need, acquisition, and installation of a portable emergency generator for an event that is expected to last more than 48 hours. ...””

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 33556 Based on observation, document review, and staff interview, it was determined that the facility failed to ensure that all facility equipment is properly maintained and ready for use at all times in one of one power generator. Findings include: During a tour conducted at 11:00 AM on 4/30/24, in the presence of Staff (S)2, Biomedical Technician, the emergency back-up generator system was found to be inoperative and as such would not be available for use in the event of a power outage. This finding was confirmed by S2 who stated the generator has been out of service since 4/11/24. S2 also stated the generator batteries were replaced in March and the generator again went into alarm 4/11/24. The generator is scheduled for repair 5/1/24, with supply chain issues being the reason for any delay. A review of facility policy titled, “Guidelines for Staff Response During Power Failure,” published 8/02/17, stated, “... In Facilities with emergency generator all equipment necessary for dialysis such as Reverse Osmosis system (R.O.), solution delivery system, and dialysis machines in addition to adequate lighting to perform dialysis must be on the emergency circuit. ...””