Caldwell Regional Medical Center

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 51768 Based on observation, policy review, and interview, the Critical Access Hospital (CAH) failed to ensure that expired equipment and supplies commonly used in life-saving procedures and for use in emergencies were removed to prevent potential use. The failure to remove expired equipment/supplies could result in ineffective treatment or complications and places all patients at risk for harm. Findings Include: Review of hospital policy titled, “POLICY NUMER:320 Monthly Outdate Checklist,” dated 09/14/2017, showed, “PURPOSE: Prevent outdated supplies and medication used in patient care area...All medication and supplies in the designated areas should be checked prior to the last day of the month...” An observation on 09/02/25 at 9:00 AM of the Pediatric Resuscitation System showed the following expired supplies: 1. Endotracheal Tubes (ET) a. One 4.0 ET expired 11/28/2024 b. One 4.5 ET expired 07/28/2024 c. One 5.0 ET expired 07/28/2025 d. One 5.5 ET expired 12/19/2024 2. Nasogastric Tubes (NG): a. Two 8 French NG expired 02/28/2025 3. IV Catheters: a. Two 20-gauge expired 11/14/2024 b. One 22-gauge expired 12/08/2024 An observation of Room 2 in the Emergency Department (ED) on 09/02/25 at 10:54 AM showed one 18 French indwelling catheter that expired on 11/30/24. During an interview on 09/02/25 at 9:19 AM, Staff C, Director of Nursing, confirmed that the Pediatric Resuscitation System contained expired supplies of endotracheal tubes, nasogastric tubes and IV catheters.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 51768 Based on observation, policy review, document review, and interview, the Critical Access Hospital (CAH) failed to ensure medications commonly used in life-saving procedures and for use in emergencies were secured. Failure to secure medications used to treat potentially life-threatening emergencies places all patients at risk for harm. Findings Include: Review of hospital policy titled, “POLICY NUMBER: 213 [Crash Cart],” dated 06/14/18, showed, “ ...Each Crash Cart will be inspected and tested at least daily to ensure the integrity of its contents and validate the defibrillator is in working order ...Once stocked again with supplies a red lock on the care and return to the Emergency Room ...” Review of Kansas Administrative Regulations Agency 28 Department of Health and Environment Article 34, “Hospitals 28-34-10a. Pharmacy services. (c) Pharmacy facilities.” current through Register 06/26/25, showed, “Each hospital that maintains a pharmacy on its premises shall provide adequate equipment, supplies and facilities for the storage, safeguarding, preparation and dispensing of drugs. Drugs and biologicals must be kept in locked storage areas ...” An observation on 09/02/25 at 9:00 AM, showed the crash cart was not secured with a lock and was accessible from a public area. An open syringe with 5% Dextrose 100ml [milliliters] and an IV [Intravenous] 18-gauge needle was laying on top of the crash cart. An observation of Room 1 in the Emergency Department (ED) on 09/02/25 at 9:19 AM, showed an unlocked and unsecured cabinet with two bags of Lactated ringers (an IV solution) 1000 ml [milliliters] and four bags of Normal Saline (an IV solution) 1000 ml. An observation of Room 2 in the ED on 09/02/25 at 10:55 AM, showed an unlocked and unsecured cabinet with two bags Lactated ringers 1000 ml and four bags of Normal Saline 1000 ml. During an interview on 09/02/25 at 9:19 AM, Staff C, Director of Nursing, confirmed that the crash cart in the ED was unlocked and stated that he/she was unaware that IV fluids required secure storage.”

“PATIENT CARE POLICIES CFR(s): These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section and updated as necessary by the CAH. This Standard is not met as evidenced by: 51768 Based on policy review and interview, the Critical Access Hospital (CAH) failed to ensure that hospital policies and procedures were reviewed at least biennially and as necessary by a group of professional personnel. This deficient practice places any patient or employee at risk for non-compliance related to failure to comply with new laws and regulations. This can result in inconsistent and outdated practices, causing poor patient outcomes and further safety concerns. Findings Include: Review of hospital policy titled, “Subject: Policy & Procedure Approval Policy,” last reviewed on 11/01/21, showed that policy reviews and revisions must be completed once every year. A collaboration between the department manager, a mid-level provider, medical director and chief executive office must occur to institute or revise any policy. Review of hospital policy titled, “Subject: Policy and Procedure Manual Review,” revised 06/19/23, showed, “ ...Nursing Policy and Procedure Manual will be reviewed and updated/revised as necessary, but at least once yearly ...” Review of the Hospital’s policies and procedure that were provided by the CAH showed the following policies were not reviewed and/or revised or signed by a group of professional personnel at least biennially: “ACLS Certification” last revised and signed on 06/29/22. “Blood Product Administration” not dated or signed by group of professional personnel and no reviews/revisions. “POLICY NUMBER:223 [Code Blue]” date initiated 09/14/17 with no signature by group of professional personnel and no reviews/revisions. “Patient Complaint and Grievance Policy” effective date 05/01/23, no reviews/revisions. “Medication Administration” last revised date 04/12/22. “POLICY NUMBER: 810 [Medication Variances]” date initiated 09/14/17 with no signature by group of professional personnel and no reviews/revisions. “Patient Leaving Against Medical Advice (AMA) / Elopement” not signed by group of professional personnel. “POLICY NUMBER: 213 [Crash Cart]” date issued 06/14/18 not signed by group of professional personnel and no reviews/revisions. “CONTROLLED DRUG MANAGEMENT” approved date 12/31/18, no reviews/revisions. “POLICY NUMBER: 806 [Inventory Control]” date issued 09/14/17 no reviews/revisions. “POLICY NUMBER: 320 [Monthly Outdate Checklist]” date issued 09/14/17 no reviews/revisions. “POLICY NUMBER: 1023 [Discharge Planning]” date initiated 04/10/21 with no signature by group of professional personnel and no reviews/revisions. “POLICY NUMBER: 1027 [Discharge Planning Process]” date initiated 04/10/21 with no signature by group of professional personnel and no reviews/revisions. “POLICY NUMBER: 1028 [Elements of Discharge Planning]” date initiated 04/10/21 with no signature by group of professional personnel and no reviews/revisions. “POLICY NUMBER: 216 [ER Discharge Instructions]” date initiated 09/14/17 with no signature by group of professional personnel and no reviews/revisions. “Policy and Procedure Manual Review” last revised 06/19/23. “Policy & Procedure Approval Policy” last revised 11/22/21. During an interview on 09/03/25 at 1:37 PM, Staff C, Director of Nursing, stated that the policies are a “mess”. During an interview on 09/04/25 at 9:40 AM, Staff A, Chief Executive Officer, stated that the policy titled, “Policy & Procedure Approval Policy,” is not current and that policies have not been up to date “like they should be.””

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 51768 Based on policy review, document review, and interview, the Critical Access Hospital (CAH) failed to ensure a registered nurse maintained current Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) certifications. This deficient practice has the potential to affect all patients by placing them at risk for delayed or inappropriate emergency care provided by non-qualified personnel. Findings Include: Review of hospital policy titled, “ACLS Certification,” dated 03/10/22, showed, “ ...All licensed nurses employed by [The Hospital] should have current ACLS certification ...Employees allowing their ACLS certification to lapse will have 30 days to get certification current. Failure to update certification within 30 days, without prior arrangements with the Director of Nursing, will result in suspension without pay until the employee becomes current with ACLS certification ...A copy of the card should be placed in employee’s personnel file ...” Review of hospital policy titled, “Code Blue, (an alert indicating a cardiac/respiratory arrest)” dated 09/14/17, showed, “ ...All nursing staff will be certified in CPR [Cardiopulmonary Resuscitation] ...” Review of Staff F, Registered Nurse (RN) personnel record on 09/04/25 failed to show documented evidence of BLS and ACLS certification on file. Review of Staff K, RN, personnel record on 09/04/25 showed that BLS and ACLS certification expired on 12/2024. During an interview on 09/04/25 at 11:10 AM, Staff C, Director of Nursing confirmed that Staff K, RN, BLS and ACLS expired in December 2024. Staff C stated that she did not track BLS and ACLS certifications for expiration dates. During an interview on 09/04/25 at 12:41 PM, Staff J, Doctor of Medicine (MD), Medical Director, stated that registered nurses working in the emergency department are expected to hold current BLS and ACLS certifications and maintain those certifications.”

“PATIENT VISITATION RIGHTS CFR(s): §485.635(f) Standard: Patient visitation rights. A CAH must have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the CAH may need to place on such rights and the reasons for the clinical restriction or limitation. A CAH must meet the following requirements: (3) Not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability. (4) Ensure that all visitors enjoy full and equal visitation privileges consistent with patient preferences. This Standard is not met as evidenced by: 51768 Based on document review, policy review, and interview, the Critical Access Hospital (CAH) failed to have policies and procedures for patient visitation. This deficient practice has the potential to affect all patients and their visitors by not ensuring consistent visitation practices and protection of visitation rights. Findings Include: Review of a hospital document titled, “CONSTITUTIONS AND BYLAWS RULES AND REGULATIONS,” last updated 08/01/25, showed that members of the Medical Staff, and the Governing Body must agree at the time of appointment to be governed by Statutes of Kansas and Federal Law, where applicable. During an interview on 09/03/25 at 10:01 AM, Staff C, Director of Nursing, stated that there is no specific policy on patient visitation rights. During an interview on 09/03/25 at 10:01 AM, Staff G, Registered Nurse, stated that visitation is allowed until 8:00 PM. Visitors need provider approval to stay later than 8:00 PM since staying later can disturb patients. The CAH failed to provide a written visitation policy and procedure upon request.”

“Establishment of the Emergency Program (EP) CFR(s): §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: 38800 Based on review of facility documents and interview, it was determined the Critical Access Hospital (CAH) failed to maintain an up-to-date comprehensive emergency preparedness program (EPP). The cumulative effect of this deficient practice has the potential to place patients and staff at risk for harm during an emergency or disaster. Findings Include: 1. The hospital failed to develop and maintain an emergency preparedness program plan (EPP) based on a facility and community-based all hazards risk assessment that addressed patient population and included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials (Refer to tag E0004, E0007 and E0009) 2. The hospital failed to develop and implement policies and procedures based on the emergency plan, address sustenance and service needs of patients, sheltering in place, and address use of volunteers and emergency staffing strategies. (Refer to tag E0013, E0015, and E0024) 3. The hospital failed to develop a policy and procedure for the facility under a 1135 Waiver and failed to have a complete and updated communication plan. (Refer to tag E0026 and E0029) 4. The hospital failed to maintain an emergency preparedness training and testing program, failed to provide initial and annual emergency preparedness training for staff, vendors, and volunteers, and failed to complete required testing exercises of the emergency preparedness plan. (Refer to tag E0036, E0037, and E0039)”

“Develop EP Plan, Review and Update Annually CFR(s): §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: 38800 Based on interview and Emergency Preparedness Program review, the Critical Access Hospital (CAH) failed to develop and maintain an emergency preparedness plan that is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach and include strategies for addressing emergency events identified by the risk assessment. This deficient practice has the potential to place patients, staff, and visitors at risk for harm or injury during an emergency. Findings Include: On 01/15/25 from 8:00 AM to 1:35 PM, review of the Emergency Preparedness Plan failed to show documented evidence of a Hazard Risk Analysis. During an interview on 01/16/25 at 10:30 AM, the EMS Director on confirmed that a Hazard Risk Analysis was in the process of being created but had not yet been completed and approved by the board.”

“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: 38800 Based on interview and Emergency Preparedness Program review, the Critical Access Hospital (CAH) failed to develop and maintain an emergency preparedness plan that addressed patient population, the services the facility has the ability to provide in an emergency; and continuity of operations including the delegation of authority and succession plan. This deficient practice has the potential to place patients, staff, and visitors at risk for harm or injury during an emergency. Findings Include: On 01/15/25 between 8:00 AM and 1:35 PM, review of the Emergency Preparedness Plan failed to show that a plan to address patient population was identified and the delegation of authority and succession plan was outdated. During an interview on 01/16/25 between 9:15 AM and 10:30 AM, the EMS Director confirmed that some names on the delegation of authority and succession plan were outdated. It was also confirmed that a policy and procedure addressing actual and potential patient population had not yet been created and approved by the board.”

“Local, State, Tribal Collaboration Process CFR(s): §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: 38800 Based on interview and Emergency Preparedness Program review, the Critical Access Hospital (CAH) failed to develop and maintain an emergency preparedness plan that includes a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency. This deficient practice has the potential to place patients, staff, and visitors at risk for harm or injury during an emergency. Findings Include: On 01/15/25 between 8:00 AM and 1:35 PM, review of the Emergency Preparedness Plan failed to show documented evidence that cooperation and collaboration attempts were made with local, tribal, regional, state, and federal emergency preparedness officials. During an interview on 01/16/25 between 9:15 AM and 10:30 AM, the EMS Director confirmed that attempts have been made to collaborate with local and regional emergency response officials, but the meetings had not yet occurred, and plans of cooperation had not yet been designed and approved by the board.”

“Development of EP Policies and Procedures CFR(s): §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: 38800 Based on interview and Emergency Preparedness Program review, the Critical Access Hospital (CAH) failed to develop and implement policies and procedures based on the facility and community-based hazard risk assessment and communication plan, utilizing an all-hazards approach. This deficient practice has the potential to place patients, staff, and visitors at risk for harm or injury during an emergency. Findings Include: On 01/15/25 between 8:00 AM and 1:35 PM, review of the Emergency Preparedness Plan failed to show documented evidence that policies and procedures were developed based on the facility and community-based risk assessment and communication plan, using an all-hazards approach. The facility failed to have a policy and procedure in place for each hazard identified in the hazard risk analysis. During an interview on 01/16/25 between 9:15 AM and 10:30 AM, the EMS Director confirmed that a Hazard Risk Analysis was in the process of being created but had not yet been completed and approved by the board. The EMS Director confirmed that the associated policies and procedures would be created based on the approved Hazard Risk Analysis.”

“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: 38800 Based on interview and Emergency Preparedness Program review, the Critical Access Hospital (CAH) failed to develop and implement policies and procedures for meeting the sustenance needs of patients, staff, and volunteers who remain in the facility during an emergency. This deficient practice has the potential to place patients, staff, and visitors at risk for harm or injury during an emergency. Findings Include: On 01/15/25 between 8:00 AM and 1:35 PM, review of the Emergency Preparedness Plan failed to show documented evidence to address sustenance and service needs of patients, staff, and volunteers who remain in the facility during an emergency. During an interview on 01/16/25 between 9:15 AM and 10:30 AM, the EMS Director confirmed that a policy and procedure to meet the sustenance needs and services had not yet been created and approved by the board.”

“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: 38800 Based on interview and Emergency Preparedness Program review, the Critical Access Hospital (CAH) failed to develop and implement policies and procedures for a means to shelter in place for patients, staff, and volunteers who remain in the facility. This deficient practice has the potential to place patients, staff, and visitors at risk for harm or injury during an emergency. Findings Include: On 01/15/25 between 8:00 AM and 1:35 PM, review of the Emergency Preparedness Plan failed to show documented evidence of a policy and procedure for sheltering in place. During an interview on 01/16/25 between 9:15 AM and 10:30 AM, the EMS Director confirmed that a policy and procedure for sheltering place had not yet been created and approved by the board.”

“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: 38800 Based on interview and Emergency Preparedness Program review, the Critical Access Hospital (CAH) failed to develop and implement policies and procedures for 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. This deficient practice has the potential to place patients, staff, and visitors at risk for harm or injury during an emergency. Findings Include: On 01/15/25 between 8:00 AM and 1:35 PM, review of the Emergency Preparedness Plan failed to show documented evidence of a policy and procedure for the use of volunteers and emergency staffing strategies. During an interview on 01/16/25 between 9:15 AM and 10:30 AM, the EMS Director confirmed that a policy and procedure for emergency staffing strategies and the use of volunteers during an emergency had not yet been created and approved by the board.”

“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: 38800 Based on interview and Emergency Preparedness Program review, the Critical Access Hospital (CAH) failed to develop and implement policies and procedures for 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. This deficient practice has the potential to place patients, staff, and visitors at risk for harm or injury during an emergency. Findings Include: On 01/15/25 between 8:00 AM and 1:35 PM, review of the Emergency Preparedness Plan failed to show documented evidence of a policy and procedure for the role of the facility under a 1135 Waiver declared by the Secretary. During an interview on 01/16/25 between 9:15 AM and 10:30 AM, the EMS Director confirmed that a policy and procedure for the role of the facility under a 1135 Waiver had not yet been created and approved by the board.”

“Development of Communication Plan CFR(s): §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This Standard is not met as evidenced by: 38800 Based on interview and Emergency Preparedness Program review the Critical Access Hospital (CAH) failed to develop and implement policies and procedures for an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated as needed. This deficient practice has the potential to place patients, staff, and visitors at risk for harm or injury during an emergency. Findings Include: On 01/15/25 between 8:00 AM and 1:35 PM, review of the Emergency Preparedness Plan failed to show documented evidence of an updated and complete communication plan. During an interview on 01/16/25 between 9:15 AM and 10:30 AM, the EMS Director confirmed that the communication plan was partially outdated. The EMS Director confirmed that the facility utilizes multiple notification systems/apps to communicate emergencies and instructions to staff, however these programs were not written in the communication plan documentation.”

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 38800 Based on interview and Emergency Preparedness Program review, the Critical Access Hospital (CAH) failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan, hazard risk assessment, policies and procedures and the communication plan. This deficient practice has the potential to place patients, staff, and visitors at risk for harm or injury during an emergency. Findings Include: On 01/15/25 between 8:00 AM and 1:35 PM, review of the Emergency Preparedness Plan failed to show documented evidence of an emergency preparedness training and testing program. During an interview on 01/16/25 between 8:15 AM and 10:30 AM, the EMS Director confirmed that an emergency preparedness training and testing program had not yet been created and approved by the board.”

“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: 38800 Based on interview and Emergency Preparedness Program review, the Critical Access Hospital (CAH) failed to develop and 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; Provide emergency preparedness training at least every 2 years; Maintain documentation of all emergency preparedness training; Demonstrate staff knowledge of emergency procedures and if the emergency preparedness policies and procedures are significantly updated, the facility must conduct training on the updated policies and procedures. This deficient practice has the potential to place patients, staff, and visitors at risk for harm or injury during an emergency. Findings Include: On 01/15/25 between 8:00 AM and 1:35 PM, review of the Emergency Preparedness Plan failed to show documented evidence of initial and annual staff, vendor, and volunteer emergency preparedness training. During an interview on 01/16/25 between 9:15 AM and 10:30 AM, the EMS Director confirmed that initial and annual training and testing on emergency preparedness was not available.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 38800 Based on interview and Emergency Preparedness Program review the Critical Access Hospital (CAH) failed to conduct the required exercises to test their emergency preparedness plan. This deficient practice has the potential to place patients, staff, and visitors at risk for harm or injury during an emergency. Findings Include: On 01/15/25 between 8:00 AM and 1:35 PM, review of the Emergency Preparedness Plan failed to show documented evidence of completed exercises for actual events, full scale community-based exercises, or full-scale facility-based excersices for 2024. Additionally, the facility failed to show evidence of mock drills documented for 2024. During an interview on 01/16/25 between 9:15 AM and 10:30 AM, the EMS Director confirmed that neither an actual event requiring the activation of the emergency preparedness plan or testing of the emergency preparedness plan occurred during 2024.”

“On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at the above-named Critical Access Hospital (CAH) from 01/15/25 to 01/16/25 resulted in a finding of compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 485.623, Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition & National Fire Protection Association (NFPA) Standard 99, 2012 edition. Caldwell Regional Medical Center is a one-story building with an attic utility storage space. The building is fully sprinklered and has a supervised smoke detection and fire alarm system and an emergency generator. The requirement of 42 CFR 485.623 is MET.”