Skyline Medical Services Inc.

“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 record reviews and interviews, the agency failed to ensure that it maintained an emergency preparedness plan that included all of the required elements and that it was reviewed and updated at least every 2 years, The agency failed to have any documentation to show that it had reviewed its Emergency Preparedness Plan, had activated the plan, or taken part in any table-top or community-based drills for three of the three years (2022, 2023, and 2024) to decide if the plan worked and to update it if needed. This failure places clients and staff at risk of poor care when the agency does not evaluate its emergency preparedness and response plan to verify its effectiveness and to improve as needed. Findings included: Review of the agency’s Emergency Preparedness Plan, revealed there were no supporting documents to show the agency had reviewed the plan or had performed annual evaluations, tabletop exercises, community-based exercises, or had activated the plan for any weather / disasters that occurred in the years 2022 (Icy weather and flash flooding), 2023 (drought conditions), or 2024 (Windstorm with rains / flooding in May 2024, and Hurricane Beryl in July 2024). During an interview with the Administrator on 1/16/2024 at 1:46 PM, when asked to provide documentation of the agency activation of the emergency plan to the weather disasters for the years 2022-2024 for the Emergency Preparedness Plan, she was unable to provide the documents. She confirmed that they have performed drills but did not document any information related to the drills. She also stated they did not know they had to activate a disaster response. She stated that she was not aware of having to document any performed drills or activate weather disaster plans if drills were performed. She confirmed she was responsible for ensuring those things were done and documented. Surveyor requested documentation of tabletop exercises and Community based exercises for the years 2022 through 2024. Admin stated she did not perform any for the years 2022 through 2024 and did not have any documentation of this being done. She stated she was unaware of this needing to be done. Review of the agency’s policy and procedure manual revealed minimal information on emergency preparedness. Review of the agency’s policy dated 5/1/08 titled “Emergency Preparedness Response Plan” read in part: “ ……… The agency maintains a written emergency preparedness and response plan… The agency will maintain documentation of compliance with its emergency plan… The agency will maintain its developed disaster plan, disaster procedures and documentation of implementation and response to the plan in a manual titled “Emergency Preparedness Plan.” ... manual will contain the following information: … an internal review of the plan at least annually, and after each actual emergency response to evaluate and to update the plan as needed; Documentation of a test of the response phase plan in a planned drill if not tested during an actual drill; and documentation of agency employees attempts to comply with plan and follow the required procedures.””