Northeastern Center

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47186 Based on document review and interview the facility failed to ensure patient received care in a safe setting by failing to establish patient well-being during 15-minute interval observation checks and in identifying environmental safety risks in 1 of 1 patient death records reviewed (P23). Findings include: 1. Facility policy/procedure titled, Seclusion, Restraint, and Emergency Intervention Procedures, Policy Number: RM1140, in effect June 2022, indicated as part of the initial nursing assessment, the R.N. will assess the patient for any special physical or medical consideration or previous trauma that may influence use of specific behavior management techniques, including emergency interventions. A notation of any special consideration to be taken will be noted on the nursing assessment and communicated with the treatment team. Emergency intervention measurers shall be used for all patients. 2. MR’s indicated P23 was in imminent danger to self/others and admitted to facility for suicidal ideation and substance abuse under Service Code 120 - Emergency Crisis Intervention, on 6/20/22 at approximately 2:46 pm. Nursing Admission Assessment at approximately 4:22 pm indicated inpatient admission reason as Suicidal and Gravely Disabled with a recent history of suicidal behavior within the last 30 days. Patient’s personal valuables/belongings were inventoried and returned on admission, including 3 pairs of pants. Inpatient Nursing DARP Progress Note evaluated P23’s level as Suicidal 0/10. Problem Statement and Action plan as patient states he/she has had suicidal ideation in the past two days, facility to provide 1:1 discussion with patient and 15-minute checks regarding patient safety status. Patient’s Individual Treatment Plan (ITP) indicated a diagnosis of suicidal ideation (SI) with barriers and limitations related to depression. Facility to monitor patient’s vital signs and symptoms of opioid withdrawal and provide medication for withdrawal relief. Strategic Interventions included assessing/prescribing medication for depression and medication effectiveness. Updated comments on ITP at approximately 9:25 pm indicated patient transferred to other facility by EMS for medical treatment. MR’s lacked documentation to address patient SI’s or how patient would remain safe. MR’s lacked patient transfer documentation. 3. Psychiatric Close Observation Record indicated security checks for patient P23’s safety at 15-minute intervals. a. 8:30 pm : I9 - patient in group room, watching TV b. 8:45 pm: F5 - patient in room (Room #205), quiet c. 9:00 pm: F5 - patient in room (Room #205), quiet d. 9:15 pm: P3 - patient in bathroom (Room 205), unresponsive 4. Inpatient Progress Note indicated medication given in the milieu and patient then went to his/her room at approximately 8:28 pm on 6/20/22. Daily Notes indicated patient found in bathroom at approximately 9:05 pm with pants wrapped around neck, 911 called, patient with faint pulse, CPR initiated and continued until EMS arrived. 5. Incident Reports reviewed indicated the following: a. N7 (Registered Nurse [RN]) indicated patient found on bathroom floor in patient room with pants wrapped around neck at approximately 9:05 pm. N7 removed pants, initiated/continued CPR until EMS arrived. b. N50 (RN) indicated he/she called 911 and then went to assist other staff in patient room with CPR until EMS arrived. c. N52 (Mental Health Technician [MHT]) indicated security doing 15 minutes checks on patient and patient was in bathroom. Fifteen minutes later, security did another patient check, and he/she was still in bathroom. Security notified N52 to perform patient check. N52 called patient name twice without response. N52 then went to get the charge nurse who returned with N52 to patient room. Charge Nurse called out to patient twice without response and then the door was opened as patient fell over backwards onto bathroom floor with pants wrapped tightly around his/her neck. An arrow sign is indicated for further documentation on this incident report, but no further documentation was provided regarding N52’s notes. d. N53 (Security Officer [SO]) indicated at approximately 9:00 pm he/she went to check on patient without any response. N53 reported this to N52 who returned to patient room #205, calling out to patient without a response. N53 and N52 went to get N7, and all returned to patient room, flipped the lights on and N53 noticed a knot above the bathroom door. When bathroom door was opened, patient’s face was blue and after CPR initiated, patient’s color began to return to his/her face. e. Facility failed to provide page 2 of 3 of the findings from N50, N7, N52 or N53. Page 3 of the Incident Reports lacked documentation of Conclusion/Follow-Up Actions/Debriefings or Comments. 6. Facility initiated/provided Root Cause Analysis (RCA) of Sentinel Event from 6/20/22. RCA did not indicate what preventative measures facility put into place to prevent future reoccurrences. 7. Critical Incident Report to Family And Social Services Administration Division Of Mental Health And Addiction indicated patient injury on 6/20/22. Critical Incident Report lacked documentation of patient death. 8. In entrance conference on 11/28/23 at approximately 9:35 am to 9:50 am, A1 (RN, Inpatient Director) indicated one facility death occurred June 20, 2022. 9. In interview on 11/29/23 at approximately 3:20 pm, A3 (Quality Improvement [QI] Coordinator) confirmed P23’s MR’s presented on scan disk at approximately 3:00 pm on 11/29/23, were complete records regarding the incident on 6/20/22. A3 confirmed P23 was not placed in an observation room but was provided 15-minute safety checks. A3 indicated procedures were changed/implemented to prevent future reoccurrences but did not articulate what specific procedures changed.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 44532 Based on document review and interview, the facility failed to ensure the use of restraint was authorized by the order of a physician or LIP (licensed independent practitioner) for two (2) of three (3) patients reviewed (P5 and P6). Findings: 1. Review of the policy titled Seclusion, Restraint, and Emergency Intervention Procedures, Policy Number RM1140, last revised February 27, 2023, indicated the following: a. All consumers have the right to be free from unnecessary restraint and seclusion of any form. Restraints are utilized only in emergent or crisis situations... b. Definitions - Restraint: Any manual method, physical device, mechanical device or pharmaceutical agent that prevents freedom of movement or normal access to the patients own body that the consumer cannot remove. c. A physician or Licensed Independent Practitioner (LIP) can authorize (order) the use of Seclusion and/or restraint. d. An RN can initiate the emergent use of Seclusion and/or Restraint until a physician or LIP order is obtained. 2. A Review of patient #5 medical record indicated the following: (A) Restrain/Seclude note dated 03/02/2023 at 1640 hours indicated that P5 was placed in a physical hold due to he/she was threatening staff, attempting to elope the building, and manic behaviors. (B) The medical record lacked a physician order for the physical hold. 3. A Review of patient #6 medical record indicated the following: (A) Restrain/Seclude note dated 08/14/2023 at 1424 hours indicated that P6 was placed in a four (4) point physical restraint due to he/she was yelling, tossing chairs, and banging on the nurses station. (B) The medical record lacked a physician order for the 4 point restraint. 4. On 11/29/2023 at 1:30 PM, AH3, Case Manager/Activity Specialist, indicated that the MR lacked an order for P5 and P6 restraint episodes listed above.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(1) Training intervals. Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion- (i) Before performing any of the actions specified in this paragraph; (ii) As part of orientation; and (iii) Subsequently on a periodic basis consistent with hospital policy. This Standard is not met as evidenced by: 44532 Based on document review and interview, the hospital failed to ensure staff ability to demonstrate competency in the application of restraints for 7 (seven) of 7 (seven) credentialed staff members (MD1, MD2, MD3, AH1, AH2, AH4, and AH5) and 5 (five) of 9 (nine) staff members personnel files. (N2, N3, N4, N7, and N9) Findings: 1. Review of the policy titled Seclusion, Restraint, and Emergency Intervention Procedures, Policy Number RM1140, last revised February 27, 2023, indicated the following: All direct care staff will be trained in patient assessment, recognition, and treatment of the problems causing the need for restraint, seclusion, and emergency intervention. Training will include alternative as well as the proper application of restraints, seclusion and emergency intervention through the use of Crisis Prevention Institute (CPI) training on the Personal Safety Plan. 2. Review of credential files of MD1, MD2, MD3, AH1, AH2, AH4, and AH5 lacked current Crisis Prevention Intervention (CPI), training. 3. Review of personnel files of N2, N3, N4, N7, and N9 lacked current Crisis Prevention Intervention (CPI), training. 4. On 11/29/2023 at 1000 hours, A5, Human Resource Director, indicated that the above staff listed are required to have current training in CPI and they all lacked current training.”

“ORGANIZATION AND STAFFING CFR(s): 482.24(a) The organization of the medical record service must be appropriate to the scope and complexity of the services performed. The hospital must employ adequate personnel to ensure prompt completion, filing, and retrieval of records. This Standard is not met as evidenced by: 47186 Based on document review and interview, facility failed to provide adequate personnel to ensure medical records compliance per policy. Findings include: 1. Facility policy/procedure titled, Content, Supervision and Control of the Client Record, Policy Number: CR8110, last revised 7/01/19, a licensed Medical Records porfessional shall be employed at least on a consultative basis to assure that clinical record procedures and Clinical Records Department procedures are adequate to meet the Center’s needs. 2. Facility failed to provide documentation of MR reviews for the previous 4 quarters. 3. In interview on 11/29/23 at approximately 2:05 pm, A3 (Quality Improvement Coordinator) confirmed MR reviews/audits have not been conducted for facility patient records the last 4 quarters. A3 indicated facility does not have qualified staff that meets policy critera.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 44532 Based on document review and interview, the infection control committee failed to ensure compliance for personnel immunizations upon hire for two (2) of nine (9) personnel files reviewed. (P6 and P9) Findings include: 1. Policy/procedure, Policy Number: FA0448, Immunization Record, last revised July 1, 2021, indicated on page 1: All inpatient staff that provides direct care must provide documentation of immunizations for or antibodies to MMR and Varicella (Chicken Pox), or by submitting a copy of an official State Immunization Form which indicates immunization. This form will be given to all direct care inpatient staff at orientation by the Nurse Manager or designee. 2. Review of personnel file indicated that P6 lacked immunization for or antibodies to Measles Mumps Rubella Vaccine (MMR) and Varicella completed upon hire. 3. A review of personnel file indicated that P9 lacked immunization for or antibodies to Measles Mumps Rubella Vaccine (MMR), Varicella, and (TB) Tuberculosis screening completed upon hire. 4. Staff A7 Human Resources Director was interviewed on 11//29/2023 at approximately 1015 hours and confirmed the above-mentioned personnel files lacked documentation of immunizations for or antibodies to upon hire.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 47186 Based on document review and interview the facility failed to ensure an appropriate transfer in 1 of 1 patient death records reviewed (P23). Findings include: 1. Facility policy/procedure titled, Patient Transfer To/From Another Facility, Policy Number PD1190, last revised 7/01/06, facility will collaborate with other facilities for the appropriate admission/transfer to and from Inpatient Services. 1. Review of P23’s ITP (Individual Treatment Plan) indicated patient transferred by EMS to other facility for medical treatment at 9:25 pm on 6/20/22. Patient’s MR’s lacked documentation of any communication/documents sent to receiving facility. 2. In interview at approximately 3:20 pm on 11/29/23, A1 (RN, Inpatient Director) indicated when an inpatient is transferred to another facility for medical needs, he/she does not document in the MR as a transfer, but considers it a discharge if the patient does not return. A1 confirmed there is no documentation in the patient medical record if the patient is transferred to another facility for medical reasons and then returns to their inpatient facility. A1 indicated verbal communication is provided to receiving facility, but no documents are sent.”

“Subsistence Needs for Staff and Patients CFR(s): §403.748(b)(1), §418.113(b)(6)(iii), §441.184(b)(1), §460.84(b)(1), §482.15(b)(1), §483.73(b)(1), §483.475(b)(1), §485.542(b)(1), §485.625(b)(1) [(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 every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal. This Standard is not met as evidenced by: 34653 Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures include at a minimum, (1) The provision of subsistence needs for staff and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical, and pharmaceutical supplies. (ii) Alternate sources of energy to maintain - (A) Temperatures to protect patients’ health and safety and for the safe and sanitary storage of provisions; (B) Emergency lighting; (C) Fire detection, extinguishing, and alarm systems; and (D) Sewage and waste disposal in accordance with 42 CFR 482.15 (b)(1). This deficient practice could affect all occupants. Findings include: Based on records review with the Risk Management Nurse on 11/28/23 between 1:00 p.m. to 3:00 p.m. and on 11/29/23 between 9:30 a.m. to 10:30 a.m., the subsistence needs documentation for the emergency preparedness program was incomplete. Documentation for sewage and waste outage was not available for review. Based on interview at the time of records review, the Risk Management Nurse stated the aforementioned policy could not be found. This finding was reviewed with the Quality Coordinator, Inpatient Director, HR director and, the Risk Management Nurse during the exit conference.”

“Procedures for Tracking of Staff and Patients CFR(s): §403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1). [(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:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility’s] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF’s, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF’s, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees’ on-duty and sheltered patients in the hospice’s care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients. This Standard is not met as evidenced by: 34653 Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures include a system to track the location of on-duty staff and sheltered patients in the facility’s care during and after an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the facility must document the specific name and location of the receiving facility or other location in accordance with 42 CFR 482.15(b) (2). This deficient practice could affect all occupants. Findings include: Based on records review with the Risk Management Nurse on 11/28/23 between 1:00 p.m. to 3:00 p.m. and on 11/29/23 between 9:30 a.m. to 10:30 a.m., a policy and procedure that includes a system to track the location of on-duty staff and patients in the facility’s care during and after an emergency was not available for review. Based on interview at the time of record review, the Risk Management Nurse stated the facility did not have a policy and procedure for tracking patients and staff during an emergency. This finding was reviewed with the Quality Coordinator, Inpatient Director and, the Risk Management Nurse during the exit conference.”

“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: 34653 Based on record review and interview, the facility failed to ensure emergency preparedness plan (EPP) include a means to shelter in place for patients, staff, and volunteers who remain in the facility in accordance with 42 CFR 482.15(b)(4). This deficient practice could affect all occupants. Findings include: Based on records review with the Risk Management Nurse on 11/28/23 between 1:00 p.m. to 3:00 p.m. and on 11/29/23 between 9:30 a.m. to 10:30 a.m., the facility’s EPP did not provide complete full written procedures for sheltering in place for patients, staff, and volunteers. Based on interview at the time of records review, the Risk Management Nurse stated there was not a sheltering in place policy that listed full procedures. This finding was reviewed with the Quality Coordinator, Inpatient Director and, the Risk Management Nurse during the exit conference.”

“Policies/Procedures-Volunteers and Staffing CFR(s): §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: 34653 Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures (EPP) include the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State or Federally designated health care professionals to address surge needs during an emergency in accordance with 42 CFR 482.15(b)(6). This deficient practice could affect all occupants. Findings include: Based on records review with the Risk Management Nurse on 11/28/23 between 1:00 p.m. to 3:00 p.m. and on 11/29/23 between 9:30 a.m. to 10:30 a.m., the provided EPP did not address the use of volunteers in an emergency. Based on interview at the time of records review, the Risk Management Nurse stated there was not a policy on the use of volunteers in an emergency provided in the EPP. This finding was reviewed with the Quality Coordinator, Inpatient Director and, the Risk Management Nurse during the exit conference.”

“Roles Under a Waiver Declared by Secretary CFR(s): §403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7). [(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:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. This Standard is not met as evidenced by: 34653 Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures (EEP) include the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials in accordance with 42 CFR 482.15(b) (8). This deficient practice could affect all occupants. Findings include: Based on records review with the Risk Management Nurse on 11/28/23 between 1:00 p.m. to 3:00 p.m. and on 11/29/23 between 9:30 a.m. to 10:30 a.m., a complete policy and procedure for the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act was not available for review. There was a sentence that stated, “If a 1135 waiver is declared, the facility will cooperate with emergency management personnel,” but information on the policies or procedures were not stated. Based on interview at the time of record review the Risk Management Nurse acknowledged the1135 waiver policy was incomplete. This finding was reviewed with the Quality Coordinator, Inpatient Director and, the Risk Management Nurse during the exit conference.”

“Methods for Sharing Information CFR(s): §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(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: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: 34653 Based on record review and interview, the facility failed to ensure the emergency preparedness communication plan includes (4) A method for sharing information and medical documentation for residents under the facility’s care, as necessary, with other health care providers to maintain the continuity of care; (5) A means, in the event of an evacuation, to release resident information as permitted under 45 CFR 164.510(b)(1)(ii); (6) A means of providing information about the general condition and location of residents under the facility’s care as permitted under 45 CFR 164.510(b)(4) in accordance with 42 CFR 482.15(c)(4). This deficient practice could affect all occupants. Findings include: Based on records review with the Risk Management Nurse on 11/28/23 between 1:00 p.m. to 3:00 p.m. and on 11/29/23 between 9:30 a.m. to 10:30 a.m., the emergency preparedness communication plan did not include a method for sharing information and medical documentation for residents under the facility’s care, as necessary, with other health care providers to maintain the continuity of care. Based on interview at the time of record review, the Risk Management Nurse stated the method for sharing information policy was not in the emergency preparedness communication plan. This finding was reviewed with the Quality Coordinator, Inpatient Director and, the Risk Management Nurse during the exit conference.”

“Information on Occupancy/Needs CFR(s): §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: 34653 Based on record review and interview, the facility failed to ensure the emergency preparedness communication EPP plan includes a means of providing information about the facility’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction or the Incident Command Center, or designee in accordance with 42 CFR 482.15(c)(7). This deficient practice could affect all occupants. Findings include: Based on records review with the Risk Management Nurse on 11/28/23 between 1:00 p.m. to 3:00 p.m. and on 11/29/23 between 9:30 a.m. to 10:30 a.m., the provided EPP communication plan did not address a means of providing information about the facility’s occupancy, needs, and its ability to provide assistance to the authority having jurisdiction or the Incident Command Center, or designee. Based on interview at the time of records review and during exit conference, the Risk Management Nurse looked through the EPP and could not find a plan that addressed a means of providing information about the facility’s occupancy, needs, and its ability to provide assistance. This finding was reviewed with the Quality Coordinator, Inpatient Director and, the Risk Management Nurse during the exit conference.”

“A Life Safety Code Recertification Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 482.41(b). Survey Date: 11/28/23 and 11/29/23 Facility Number: 003734 Provider Number: 154050 AIM Number: 200404950A At this Life Safety Code survey, Northeastern Center was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies. This one story facility with an atrium was determined to be of Type V (000) construction and was fully sprinklered. The facility has a fire alarm system with smoke detection in the corridors, spaces open to the corridors and patients rooms. The facility has a capacity of 16 and had a census of 4 on 11/28/23 and 6 on 11/29/23. Quality Review completed on 11/30/23”