Maniilaq Health Center

“EP Program Patient Population CFR(s): §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(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 the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[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. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: 40259 . Based on interview and record review, the facility failed to ensure their Emergency Preparedness plan addressed patient populations or persons at-risk during an emergency and what types of services the facility had the ability to provide. Specifically, the facility did not include a plan for the boarding of community members in the hospital when community resources were not available to meet their disability-specific needs during an emergency. This failed practice had the potential to place community members requiring emergency shelter at risk of a delay in response from the hospital, a delay in potential emergency needs, and loss of continuity of care due to an inconsistent plan in an emergency event. Findings: During an interview on 3/17/26 at 3:40 PM, the facility’s Safety Officer stated on 2/25/26 a community member who was bed bound with limited mobility required emergency shelter due to a burst sprinkler in his/her apartment complex which caused flooding in his/her apartment. Community resources were not available to house this community member, so the hospital initiated the EP plan to board the community member in the hospital. During an interview on 3/17/26 at 3:5 PM, the hospital’s Vice President of Health Services stated when a community member boarded in the hospital, they were responsible for themselves, and family was to assist to meet their needs to include meals and drinks. Family also would need to stay with the community member at night and if the community member required any medical attention they would need to go to the facility’s Emergency Room for assessment. Review of an email written by the Safety Officer, dated 3/17/26 at 4:38 PM, revealed: “ ... Under our Emergency Operations Plan [EOP] ... the EOP is an all-hazards, continuity-of-operations framework designed to guide response to both internal and external incidents that impact patient safety, and the surrounding community. In this situation, we had an external environmental hazard ... No other community-based placement was available or capable of safely accommodating a bedbound individual ... When external resources are unavailable, the EOP supports the use of available internal resources to ensure continuity of care and protection of individuals at risk ... To be clear, and consistent with patient management considerations on page 24, this was not an inpatient admission. There was no admission order, no observation status, and no billing associated with lodging. No inpatient services were initiated beyond basic safety oversight. This was a temporary, non-clinical placement solely for life safety purposes ...” Review of the facility’s “Emergency Operations Plan (EOP) 2025,” revealed: 1. The EOP’s Hazard Vulnerability Assessment (HVA) did not include the boarding of community members when community resources were unavailable; 2. The EOP’s HVA did mention “shelter in place,” however the EOP had no procedure or protocol for this potential emergency; 3. Page 24 of the facility’s EOP addressed “Staff Support Activities,” “Licensed Independent Practitioners (LIPs) and Volunteers,” “Verification of LIPs and Volunteers,” “Utilities,” and “Patients” however did not have any procedure or protocol for the boarding of community members in a non-admission manner; and 4. There was no procedure or protocol outlined in the facility’s EOP to specify what expectations for “basic safety oversight” (as stated in the email) of boarded community members were to be followed. During an interview on 4/7/26 at 2:00 PM, the Chief Nursing Officer stated there was no documentation of any interactions between hospital staff and boarded community members during their stay, no documentation of requests made by boarded community members to staff, or any documentation of staff interventions (if any) with a boarded community member because they were not considered patients. During an interview on 4/9/26 at 2:59 PM, the Vice President of Health Services and the Director of Quality and Accreditation both stated there was no policy or procedure for the boarding of community members within the hospital during an emergency event. During an interview on 4/10/26 at 8:15 AM, when asked about procedures or protocols for boarding community members in the facility’s EOP, the Safety Officer stated boarding was not part of the EOP plan. The Safety Officer further stated there was no facility policy for the boarding of community members in the hospital. .”

“Policies/Procedures for Sheltering in Place CFR(s): §403.748(b)(4), §416.54(b)(3), §418.113(b)(6)(i), §441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.542(b)(4), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3). (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:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to ensure their Emergency Preparedness plan addressed a means to shelter in place for patients, staff, and volunteers who remain in the facility. This failed practice placed all hospital patients at risk for receiving less than optimal care and services during an emergency. Findings: Review of the facility’s “Emergency Operations Plan (EOP) 2025,” revealed no method or means to shelter in place for patients, staff, and volunteers who remain in the facility. During an interview on 4/10/26 at 8:15 AM, the facility’s Safety Officer stated their EOP had no procedure or protocol for sheltering in place and this was a gap that would be addressed. .”

“EP Training Program CFR(s): §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to ensure their Emergency Preparedness training included: 1) the boarding of community members in the hospital when community resources were not available; and 2) sheltering in place of patients, staff, and volunteers who remain in the facility during an emergency. These failed practices placed all inpatients and community members at risk for delay in emergency response during a disaster. Findings: Review of the facility’s “Emergency Operations Plan (EOP) 2025,” revealed: 1) no method for the boarding of community members in the hospital when community resources were not available to meet their disability-specific needs during an emergency; and 2) no method or means to shelter in place for patients, staff, and volunteers who remain in the facility. Review of an email, dated 4/9/26 3:59 PM, when asked if staff were provided formal education on the procedure and/or protocol on the boarding of community members, the Director of Quality and Accreditation stated “ ... it is something that has been verbally done with staff ...” During an interview on 4/9/26 at 2:59 PM, the Vice President of Health Services and the Director of Quality and Accreditation both stated there was no policy or procedure for the boarding of community members within the hospital during an emergency event. During an interview on 4/10/26 at 8:15 AM, the facility’s Safety Officer stated their EOP had no procedure or protocol for sheltering in place and this was a gap that would be addressed. .”