Puget Sound Kidney Center - Monroe

“Procedures for Tracking of Staff and Patients CFR(s): §403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1). [(b) Policies and procedures. The [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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility’s] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF’s, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF’s, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees’ on-duty and sheltered patients in the hospice’s care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients. This Standard is not met as evidenced by: 30177 Based on an interview and review of the facility’s emergency preparedness plant, the facility failed to ensure leadership, who was responsible for its emergency preparedness program, could describe the tracking system it would employ to document the locations of patients and staff in the event of an evacuation. The facility’s failure to ensure staff was able to describe the tracking system that would be used in the event of an evacuation had the potential to affect the safe evacuation of all staff employed at this facility, the 22 in-center hemodialysis patients, and the 12 peritoneal patients cared for by this facility. Findings include: A review of the facility’s undated “Emergency Preparedness Plan” indicated, “The Named Facility” tracks the location of patients and staff in a disaster. After a disaster, it will be important for the organization to be able to locate patients and staff for care coordination, operational planning, communication with family and friends, and communication with the emergency personnel...” In an interview on 10/30/24 at 11:03 AM, the Clinical Manager revealed he/she was unaware of the tracking process the facility would use in the event of evacuation of the patients and staff.”

“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: 30177 Based on an interview and review of the facility’s emergency preparedness plan, the facility failed to ensure the emergency preparedness program included a policy and procedure on how the facility would acquire emergency drugs in the event of shortages. The facility’s failure to develop a policy to acquire drugs in the event of a shortage had the potential to delay life-sustaining medical care to patients. The failed practice had the potential to affect the 22 in-center hemodialysis patients, and the 12 peritoneal patients cared for by this facility. Findings include: A review of the facility’s undated “Emergency Preparedness Plan” revealed the plan did not include a method for the facility to acquire emergency drugs in the event of shortages. In an interview conducted on 10/30/24, at 11:03 AM, a request was made to review the facility’s policy on obtaining emergency medications during shortages. The Chief Nursing Officer (CNO) stated that the emergency plan did not include a procedure for acquiring medications in the event of shortages. Additionally, the facility had not developed a policy for retrieving medications under such circumstances.”