Sunrise County Home Care Services, LLC

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must 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: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on document reviews and interviews, it was determined that the Condition of Participation for Emergency Preparedness was not met as the agency failed to ensure that the Emergency Preparedness Plan was reviewed and updated every year and that all policies and procedures were updated and reviewed every two (2) years. Findings: 1. Standard: §484.102(a) also known as E-0004 - Based on document reviews and interviews, agency staff failed to ensure that the Emergency Preparedness Plan was reviewed and updated every year. See findings under E-0004 for details. 2. Standard: §484.102(b) also known as E-0013 - Based on document reviews and interviews, the facility failed to ensure that all policies and procedures were updated and reviewed every two (2) years. See findings under E-0013 for details. The cumulative effect of these deficient practices resulted in noncompliance with this Condition of Participation.”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §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: Based on document reviews and interviews, it was determined that the agency failed to ensure the Emergency Preparedness Plan was updated and reviewed annually. Findings include: A review of the Healthways/Regional Medical Center at Lubec/Sunrise County Homecare Services policy dated 10/26/2017 states in part, ...”SCHS’S Emergency Preparedness Plan (EPP) is fully integrated with HealthWays/Regional Medical Center at Lubec’s (HW/RML) Emergency Preparedness Plan (EPP), however this policy outlines procedures unique to SCHS”. The review of the HealthWays/Regional Medical Center at Lubec Emergency Preparedness Plan revealed that it was last updated and reviewed in 2019. On 4/16/2024 at 12:11 PM, an interview was conducted with the Senior Human Resources Director and the Administrator, who confirmed that the Emergency Preparedness Plan had not been updated and reviewed since 2019. .”

“Development of EP Policies and Procedures CFR(s): 484.102(b) §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: Based on document reviews and interviews, it was determined the agency failed to ensure that Emergency Preparedness policies and procedures were updated at least every two (2) years. Findings include: A review of the Healthways/Regional Medical Center at Lubec/Sunrise County Homecare Services policy dated 10/26/2017, stated in part ...”SCHS’S Emergency Preparedness Plan (EPP) is fully integrated with HealthWays/Regional Medical Center at Lubec’s (HW/RML) Emergency Preparedness Plan (EPP), however this policy outlines procedures unique to SCHS”. A review of the Healthways/Regional Medical Center at Lubec policy Emergency Preparedness Management last reviewed 3/31/2021, stated in part...”The purpose of this policy is to ensure that Healthways/Regional Medical Center at Lubec (HW/RMCL) and its employees has access to information that prepares them to react to emergencies and disasters that occur within HW/RMCL facilities and communities it serves...The Emergency Preparedness Committee (EPC) is responsible for evaluating and maintaining the Emergency Preparedness Plan”. On 4/16/2024 at 12:20 PM, an interview was conducted with the Senior Human Resources Director and the Clinical Manager, and it was confirmed that the Emergency Preparedness policies and procedures had not been reviewed and updated since 2017 and 2021.”