Rule/Regulation Violated:
§403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies.
Evidence/Findings:
Based on record review and staff interviews it was determined the hospice failed to develop procedures outlining primary and specific alternate means for communication with Federal, State, tribal, regional, and local emergency management agencies. This deficient practice has the potential that communication may be delayed or lacking in the event of an emergency posing the risk for negative patient and staff outcomes.
Summary:
The following deficiencies were found during the unannounced on-site State Compliance survey conducted on August 27, 2025 for Survey #1D4E8F-HI.Compliance Officer 08/27/2025