Camino De Salud Nursing Care

“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 review and interview, the agency failed to develop and maintain an Emergency Preparedness and Response Plan (EPRP) separately for each licensed HCSSA entity. This was evidenced by the agency maintaining and updating one combined EPRP for LIC# 014046 and LIC# 021444. Although the EPRP included the required emergency preparedness components and both licensed entities were identified in the plan, the agency developed, maintained, and updated the EPRP as one combined plan rather than separately for each licensed HCSSA entity. The failure had the potential to place clients at risk for delayed or disrupted care during an emergency or disaster because emergency preparedness needs, response procedures, and responsibilities for each separately licensed HCSSA entity were not separately identified and addressed in the Emergency Preparedness and Response Plan. During an interview conducted with the Alternate Administrator on 07/31/2026 at 12:33 PM, the Alternate Administrator confirmed that the agency operated under two separately licensed HCSSA entities, LIC#014046 and LIC#021444. The Alternate Administrator stated that the two entities were maintained separately during 2022 and the beginning of 2023; however, in 2023, she combined the operations of both entities, believing this was permissible. The Alternate Administrator stated that she was unaware that the two separately licensed HCSSA entities were required to operate independently. The Alternate Administrator confirmed that the agency had Emergency Preparedness (EP) policies and procedures in place. The Alternate Administrator stated that the same EP policies and procedures were used for both separately licensed HCSSA entities and did not separately address the emergency preparedness operations, responsibilities, and response procedures applicable to LIC#014046 and LIC#021444. The Alternate Administrator confirmed that the agency maintained one Emergency Preparedness and Response Plan (EPRP) for both separately licensed HCSSA entities and that the EPRP was developed, maintained, and implemented as one combined plan for both entities. Review of the agency’s Emergency Preparedness policies and procedures revealed that the agency had policies and procedures addressing emergency preparedness; however, the policies and procedures did not address how the EPRP would be separately developed, maintained, and implemented for LIC#014046 and LIC#021444. The policies and procedures addressed emergency preparedness as one combined operation for the two separately licensed HCSSA entities.”