Sunrise Health Services

“HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA 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:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This Standard is not met as evidenced by: Based on interview, review of policy and procedure and review of facility documents, the Department has determined the Administrator failed to ensure that policies and procedures were in place to clearly outline transfer arrangements for patient care in the event that a more acute level of care were needed for the patient(s) or in the event of facility impairment or closure. Failure to prepare for the possibility of patient transfer in the event of an emergency event can result in patients without any ability to access needed care, resulting in patient harm or death. Findings include: A review of the Centrix/Sunrise Emergency Operations Plan revealed that patients requiring other care would go to their nearest hospital. A request was made for any transfer agreements or other agreements made with local hospitals, residential care, long-term care facilities or any other facilities, but these agreements could not be provided. No plan for transportation of patients could be provided. A subsequent interview with Employee #1 conducted on April 24, 2024 indicated that Employee #1 acknowledged there were no transfer agreements in place and no policies or procedures in place regarding what to do with patients should they need to be transferred to another facility in the event of an emergency either due to facility closure or due to the need of critical care.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(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:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on interview, review of policy and procedure and review of facility documents, the Department has determined the Administrator has failed to ensure a policy is created for the provision of volunteers during an emergency event. Failure to ensure there is a policy for the provision of volunteers during an emergency event can result in unqualified medical volunteers or nonmedical volunteers being allowed to have access to patients. Findings include: A review of the Centrix/Sunrise Emergency Preparedness Plan, facility policy titled, “...Emergency and Disaster Preparedness Plan....” revised April 2, 2023 and “...Emergency Operations Plan....” revised April 1, 2021 indicated no policy regarding the admittance and credentialing of medical and nonmedical volunteers during an emergency event. A request was made for a policy regarding the admittance of volunteers during an emergency event but this policy could not be provided. During a subsequent interview conducted with Employee #1 on April 24, 2024, Employee #1 acknowledged there was no policy, nor was there a written procedure for the admittance of medical or nonmedical volunteers during an emergency event.”

“Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: Based on interview, review of policy and procedure and review of facility documents, the Department has determined the Administrator failed to ensure that a policy or procedure exists to provide information about the facility’s needs or ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. Failure to have a policy or procedure in place to provide information on needs or ability to provide assistance in the event of an emergency can result in resources not being provided to the community or in patients not receiving the care they require. Findings include: Based on interview, review of policy and procedure and review of facility documents revealed no policy or procedure that provided information about the facility’s needs or ability to provide assistance to the AHJ (authority having jurisdiction) or Incident Command in the review of the Centrix/Sunrise Emergency Preparedness plan, “...Emergency and Disaster Preparedness Plan....” policy revised 04/02/2023, or “...Emergency Operations Plan....” revised April 1, 2021. In a subsequent interview conducted on April 24, 2024, Employee #1 acknowledged there was no policy or procedure that could be provided.”