Fresenius Kidney Care North Suffolk Home

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 45736 Based on interview and document review it was determined the facility’s staff failed to document the review and/or update of the emergency preparedness (EP) plan at least every two years. The findings include: Surveyor review of the facility’s EP plan, including policies and procedures associated with the plan, was conducted on 4/15/24 with the assistance of Staff Member #1 and Staff Member #2. The surveyor asked for evidence documenting a date the emergency preparedness plan was last reviewed and/or updated. The last update to the EP plan was documented as August 2021. During an interview on 4/15/24 Staff Member #1 and Staff Member #2 stated that they recognized that their review and/or update of the plan was out of date and this was something they needed to address. This information was shared with Staff Member #1 and Staff Member #2 during the review of the emergency plan on 4/15/24 and again at the exit conference on 4/15/24.”

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(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. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 45736 Based on observation and facility policy review, the facility staff failed to remove expired supplies from the emergency cart. The findings included: During the flash tour on 4/15/24, this surveyor conducted a review of the contents of the facility’s emergency cart and evacuation kit. The surveyor found two (2) - vials of diphenhydramine 50 mg/mL- expired 02/2024. At the time of discovery the surveyor notified Staff Member #1 of the expired medications. Staff Member #1 immediately removed the expired vials. Twelve (12) vials of diphenhydramine 50 mg/mL, that were not expired, remained in the emergency cart for use. On 4/15/24, a review of the facility’s policy titled, “Emergency Medication, Equipment and Supplies”, published 05/01/2023, version 6, was conducted and read, in part: “...Emergency cart:...The emergency cart must be:...Checked monthly or after use for contents, expiration dates... Items approaching expiration must be reordered and replaced prior to the actual expiration date...”. This information was shared with Staff Member #1 and Staff Member #2 during the exit conference on 4/15/24.”