Missing Documentation of Emergency Transfer Arrangements
Summary
The facility failed to maintain an Emergency Operations Plan (EOP) that included required documentation of arrangements with other facilities or providers to receive residents in the event of limitations or cessation of operations. During a record review and interview with the Safety Director, surveyors found that the facility could not provide evidence of such agreements or arrangements as mandated by federal regulations. The Safety Director stated that there was an agreement with the county, but was unable to produce any documentation to support this claim. This lack of documented arrangements was identified during the review of the EOP and confirmed in the interview, resulting in a deficiency related to emergency preparedness and continuity of care for residents.
Plan Of Correction
Immediate Corrections: The Emergency Management binder and missing documentation were located and returned to the AHDL site. See attached Kern County Emergency Operation Manual, ADHL KCHCC Partner Participation Agreement, and the AH Delano Grant Letter. All residents had the potential to be affected by this issue, but no harm was identified for any residents. Sustainment: The Accreditation Manager educated the Facilities Manager on the requirement to maintain the Emergency Operations Manual on site at all times, and to not allow the binder to be removed for any reason, even short term use. Likewise, the Emergency Management Manager was also educated to complete any updates or changes to the manual on site, and not to take it to another location to work on it. Monitoring: The Manager of Facilities will verify the binder is in the unit at least monthly to ensure that the Manual is still on site and has not been removed. This will continue for 6 months to ensure sustainment. Data will be reported out to the SCU Quality Assurance Committee as part of the QAPI program. Person Responsible: Facilities Manager E 025
Penalty
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors identified that the facility's memorandum of understanding with partner facilities and providers, required for emergency preparedness, was expired at the time of review. The Administrator confirmed the agreement was not current and renewal was pending, resulting in noncompliance with emergency preparedness regulations.
The facility failed to establish necessary arrangements with other facilities and providers to ensure continuity of services during emergencies. This deficiency was confirmed during a documentation review and an exit interview with the Assistant Administrator and Maintenance Director.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Expired Emergency Operations Agreement
Penalty
Summary
The facility failed to maintain an up-to-date Emergency Operations Plan (EOP) as required by federal regulations. During a record review and interview with the Administrator, surveyors found that the memorandum of understanding with partner facilities and providers, which is necessary to ensure the continuity of services to residents in the event of limitations or cessation of operations, was expired. The agreement provided by the facility had an expiration date in February 2025, and at the time of the survey, it was no longer valid. The Administrator confirmed during the interview that the agreement was expired and stated that renewal was in process. This lapse in maintaining a current arrangement with other facilities could affect the facility's ability to properly respond during an emergency, as required by the emergency preparedness regulations. No specific residents or medical histories were mentioned in relation to this deficiency.
Plan Of Correction
Sierra View Medical Center Distinct Part Skilled Nursing Unit submits this plan of correction as part of the requirement under the State and Federal regulations. The plan of correction is submitted and shall not be construed as admission to the alleged deficiency cited or any liability. The plan of correction shall constitute a credible allegation of compliance. Potential Patients affected The organization was unable to find in a retrospective review that any patients had been adversely affected and were not placed in an immediate jeopardy situation. Immediate Organizational Action During document review, it was noted that the Hospital's Memorandum of Understanding (MOU) with its regional partners had expired on February 26, 2025. The MOU is normally updated by the EMS Coordinator-Disaster Services Fresno County MHOAC and sent out for all parties to agree upon. The Environment of Care/Safety & Security Manager from Sierra View notified the coalition of the need for an updated MOU. The EMS Coordinator from Fresno County then submitted an addendum to the coalition for an extension of the MOU until December 31, 2025. All parties agreed and the amendment to the MOU was officially updated. (Please see attachments A & B highlighted areas) Organizational System Improvements: Persons responsible: Environment of Care/Safety & Security Manager The Environment of Care/Safety & Security Manager will attend regular meetings with the coalition to ensure the MOU does not lapse. PI Monitoring: The MOU will be presented no less than annually to the organization’s Safety Committee for tracking purposes.
Failure to Establish Emergency Arrangements with Other Facilities
Penalty
Summary
The facility was found deficient in its emergency preparedness policies and procedures, specifically in the development of arrangements with other facilities and providers. During a documentation review, it was revealed that the facility failed to establish necessary agreements to ensure the continuity of services to patients in the event of limitations or cessation of operations. This deficiency affects the entire component of the facility's emergency preparedness plan. An exit interview with the Assistant Administrator and the Maintenance Director confirmed the lack of arrangements with other facilities. This oversight indicates a failure to comply with the regulatory requirement to maintain continuity of care for patients during emergencies, as outlined in the relevant sections of the federal regulations. The deficiency was identified during a survey conducted on December 23, 2024.
Plan Of Correction
Emergency preparedness plan has been reviewed and updated to include facility has made arrangements with other facilities and providers to receive residents in event of an emergency. NPE/designee will re-educate maintenance staff on timely updates for policies and procedures relating to arrangements for residents in the event of an emergency. NHA/designee will complete weekly audits to ensure EPP manual is updated and facility has made arrangements with other facilities and providers to receive residents in event of an emergency. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.
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