Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 65C0001001	(X3) Date Survey Completed 02/08/2019
Name of Provider or Supplier Hafa Adai Specialist Group, Llp	Street Address, City, State Sunflower Villa, 280 Pale San Vitores, Tamuning, GU
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag	Summary Statement of Deficiencies (Each deficiency should be preceded by full regulatory or LSC identifying information)
E0000	42 CFR 416.54 A direct federal survey was conducted on January 31, 2019, February 1, 2019 and February 8, 2019. The survey was conducted in part, in accordance with 42 Code of Federal Regulations, Part 416.54: Condition for Coverage - Emergency Preparedness. At the survey's conclusion, Hafa Adai Surgical Group was found not to be in compliance with the requirements for coverage in Medicare and Medicaid
E0004	Develop EP Plan, Review and Update Annually CFR(s): 416.54(a) §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), §485.625(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: Based on interview with the facility's office manager and document review of the emergency preparedness plan the facility has not reviewed and updated their emergency preparedness plan on an annual basis as required. Lack of an annual review and update of the emergency preparedness plan could result in obsolete or outdated information and procedures which could compromise the safety of all patients and staff. This could affect all of the facility's patients and staff. Findings: On February 1, 2019, between approximately 1PM and 330PM, during the review of the facility's emergency preparedness program the office manager was asked to present a copy of the emergency preparedness plan. The office manager presented a document titled "Introduction To Disaster Safety Plan". The table of content lists the following components of the plan. Earthquake Evacuation Plan Bomb & Bomb Threat Evacuation Plan Tsunami Evacuation Plan Landslide Evacuation Plan Typhoon Preparation Plan Disaster Recovery Plan The plan also contains inserts for the Fire Response Plan and Fire Prevention. The office manager was asked if the plan had been reviewed and updated within the past year. He replied "no". The most recent revision date of any document in the plan was dated September 29, 2009.
E0006	Plan Based on All Hazards Risk Assessment CFR(s): 416.54(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice 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: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. [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 the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. [For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID 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: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on interview with the facility's office manager and document review of the emergency preparedness plan the facility has not performed a risk assessment of the hazards specific to the facility's geographic location as required. Without performing a risk assessment the facility may not prioritize resources in order to mitigate those hazards which present the greatest threat. This could affect the safety of all staff and patients. Findings: On February 1, 2019, between approximately 1PM and 330PM, during the review of the facility's emergency preparedness program the office manager was asked if the facility had performed a risk assessment on the hazards for which they had based their emergency plan. The office manager said the facility had not performed a risk assessment. A risk assessment was not found during the review of the emergency plan.
E0007	EP Program Patient Population CFR(s): 416.54(a)(3) §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), §485.625(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: Based on interview with the facility's office manager and document review of the emergency preparedness plan the facility's emergency preparedness plan does not address the following, as required: * Services the facility would be able to provide during an emergency Plans to continue operations during an emergency Delegations of authority and succession plans. Without incorporating these requirements in the emergency preparedness plan there is no source of information to guide staff in what services the facility could offer to other healthcare facilities, no provisions for operating during an emergency and no clear guidance on who would be making decisions affecting the operations of the facility and the health care of patients. This could affect all of the facility's patients and staff. Findings: On February 1, 2019, between approximately 1PM and 330PM, during the review of the facility's Emergency preparedness program no provisions that address these requirements were found. The office manager said these requirements were not addressed in the plan.
E0009	Local, State, Tribal Collaboration Process CFR(s): 416.54(a)(4) §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), §485.625(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: Based on interview with the facility's office manager and document review of the emergency preparedness plan the facility's plan does not include a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials. It also does not document the facility's efforts to contact such officials, as required. Without a process for cooperation and collaboration the facility may not be able to share resources with other facilities so that the needs of their own patients and those of other health care facilities can be provided for during an emergency. Without documentation of the facility's efforts to contact emergency preparedness officials the facility may not have the knowledge or ability to contact these official with requests for help or offers to help others during an emergency. This could affect all of the facility's patients and staff. Findings: On February 1, 2019, between approximately 1PM and 330PM, during the review of the facility's Emergency preparedness program no process for cooperation and collaboration was addressed in the plan. The plan did not contain any contact information or document any efforts to contact emergency preparedness officials. The office manager confirmed that this documentation was not in the facility's emergency plan.
E0018	Procedures for Tracking of Staff and Patients CFR(s): 416.54(b)(1) §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), §485.625(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: Based on interview with the facility's office manager and document review of the emergency preparedness plan the facility's plan does not have any policies or procedures which address a system to track the location of on duty staff and sheltered patients, as required. Without any policies and procedures to track the location of on duty staff and sheltered patients there is no guidance for the facility to implement should relocation become necessary. This could result in important medical information, medication or equipment required by patients not being forwarded to locations where patients have been sent. This could affect all of the facility's patients and staff. Findings: On February 1, 2019, between approximately 1PM and 330PM, during the review of the facility's Emergency preparedness program no policies or procedures were observed in the facility's plan which addresses a system to track the location of on duty staff and sheltered patients. The office manager confirmed that there were no such policies and procedures.
E0020	Policies for Evac. and Primary/Alt. Comm. CFR(s): 416.54(b)(2) §403.748(b)(3), §416.54(b)(2), §418.113(b)(6)(ii), §441.184(b)(3), §460.84(b)(3), §482.15(b)(3), §483.73(b)(3), §483.475(b)(3), §485.68(b)(1), §485.625(b)(3), §485.727(b)(1), §485.920(b)(2), §491.12(b)(1), §494.62(b)(2) [(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:] [(3) or (1), (2), (6)] Safe evacuation from the [facility], 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 RNHCIs at §403.748(b)(3) and ASCs at §416.54(b)(2):] Safe evacuation from the [RNHCI or ASC] which includes the following: (i) Consideration of care needs of evacuees. (ii) Staff responsibilities. (iii) Transportation. (iv) Identification of evacuation location(s). (v) Primary and alternate means of communication with external sources of assistance. [For CORFs at §485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at §485.727(b)(1), and ESRD Facilities at §494.62(b)(2):] Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services; and ESRD Facilities], which includes staff responsibilities, and needs of the patients. * [For RHCs/FQHCs at §491.12(b)(1):] Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; staff responsibilities and needs of the patients. This STANDARD is not met as evidenced by: Based on interview with the facility's office manager and document review of the emergency preparedness plan the policies and procedures in the facility's evacuation plan does not consider, the care of evacuees, the means of transportation or primary/alternate means of communication with outside sources of assistance, as required. Without these considerations there are no contingencies for the needs of staff and patients and no transportation is provided in the event the facility cannot be occupied. No methods or information for contacting outside assistance is provided. This could affect all of the facility's patients and staff. Findings: On February 1, 2019, between approximately 1PM and 330PM, during the review of the facility's emergency preparedness program no policies or procedures, associated with the safe evacuation of the facility were observed that consider the care needs of evacuees, transportation and primary/alternate means of communications with external sources of information. The office manager said that there were no other emergency preparedness policies and procedures.
E0022	Policies/Procedures for Sheltering in Place CFR(s): 416.54(b)(3) §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), §485.625(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: Based on interview with the facility's office manager and document review of the emergency preparedness plan the facility's plan does not include policies and procedures for how it will provide a means to shelter in place for patients, staff and volunteers who remain in the facility, as required. Without these policies and procedures the facility may not be able to provide for a safe environment which assures basic needs are provided for those who are sheltered in place. This could affect all of the facility's patients and staff. Findings: On February 1, 2019, between approximately 1PM and 330PM, during the review of the facility's Emergency preparedness program no policies or procedures were observed which provides a means for patients, staff and volunteers to shelter in place. The office manager said there were no other emergency preparedness policies and procedures.
E0023	Policies/Procedures for Medical Documentation CFR(s): 416.54(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(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:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. [For RNHCIs at §403.748(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. [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. This STANDARD is not met as evidenced by: Based on interview with the facility's office manager and document review of the emergency preparedness plan the facility's emergency preparedness policies and procedures do not address a system of medical documentation that preserves patient information, protects confidentiality of this information and which secures and maintains the availability of these records, as required. Without addressing these requirements patient information could be compromised and the information within these records may not be available to aid in a patient's healthcare needs. This could affect all of the facility's patients. Findings: On February 1, 2019, between approximately 1PM and 330PM, during the review of the facility's emergency preparedness program no policies or procedures were observed which address the preservation and confidentiality of patient information or the assurance that these records would be secure and available. The office manager said there were no other emergency preparedness policies and procedures.
E0024	Policies/Procedures-Volunteers and Staffing CFR(s): 416.54(b)(5) §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), §485.625(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: Based on interview with the facility's office manager and document review of the emergency preparedness plan the facility's emergency preparedness policies and procedures do not address the requirement for the use of volunteers in an emergency or provide for other staffing strategies to address surge needs during an emergency, including the process of integration and role of state and federally designated health professionals, as required. Without addressing these requirements the facility may not have enough staff to address the needs of patients at their facility or those transported to other facilities, during an emergency. This could affect all of the facility's patients and staff. Findings: On February 1, 2019, between approximately 1PM and 330PM, during the review of the facility's emergency preparedness program no policies or procedures were observed which address the requirement for the use of volunteers in an emergency. The office manager said there were no other emergency preparedness policies and procedures.
E0026	Roles Under a Waiver Declared by Secretary CFR(s): 416.54(b)(6) §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), §485.625(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: Based on interview with the facility's office manager and document review of the emergency preparedness plan the facility's emergency preparedness policies and procedures do not address the role of the facility under an 1135 waiver for the provision of care and treatment at an alternative care site, as required. Addressing this role assures that health care items and services are available to those in need during an emergency and that providers who provide services in good faith are reimbursed and exempted from sanctions. This could affect all of the facility's patients as well as other potential patients from other facilities. Findings: On February 1, 2019, between approximately 1PM and 330PM, during the review of the facility's emergency preparedness program no policies or procedures were observed which address the role of the facility under an 1135 waiver. The office manager said there were no other emergency preparedness policies and procedures.
E0029	Development of Communication Plan CFR(s): 416.54(c) §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), §485.625(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: Based on interview with the facility's office manager and document review of the emergency preparedness plan the facility's emergency preparedness plan does not include a written communication plan. Without such a plan the facility has no assurance that they will be able to communicate with outside sources of help during an emergency. This could delay patient evacuation efforts to facilities that may still have the means to care for patients. It could also delay the passing of requests for medical or other supplies from outside entities. Staff, including volunteers, and physicians could not be notified promptly. This could affect all of the facility's patients and staff . Findings: On February 1, 2019, between approximately 1PM and 330PM, during the review of the facility's emergency preparedness program no communication plan was observed. The office manager confirmed that the emergency preparedness program did not include a communication plan.
E0036	EP Training and Testing CFR(s): 416.54(d) §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), §485.625(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, 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: Based on interview with the facility's office manager the facility has not developed or maintained an emergency preparedness training and testing program. Without such a training and testing program the facility may not be able to provide for the needs of patients and staff during and after an emergency event. This could affect all of the facility's patients and staff. Findings: On February 1, 2019, between approximately 1PM and 330PM, during the review of the facility's emergency preparedness program the office manager was asked if the facility had provided emergency training and testing for the staff. The office manager said that the facility had not provided for any emergency training or testing based on the facility's emergency preparedness plan.
K0000	42 CFR 416.44 A direct federal recertification survey was conducted on January 31, 2019, February 1, 2019 and February 8, 2019. The survey was conducted in part, in accordance with 42 Code of Federal Regulations, Part 416.44: Condition for Coverage - Environment. At the survey's conclusion, Hafa Adai Surgical Group was found not to be in compliance with the requirements for coverage in Medicare and Medicaid. Date Built: Before 2009 Construction Type: Type I No. of Stories: 3 Ground Floor is occupied by Hafa Adai Specialty Group First/Second Floor: rental apartments Facility Address: Hafa Adai Specialty Group Sunflowervilla Bldg. 280 Pale San Vitores Rd. Tamuning, GU 96913
K0131	Multiple Occupancies CFR(s): NFPA 101 Multiple Occupancies - Sections of Ambulatory Health Care Facilities Multiple occupancies shall be in accordance with 6.1.14. Sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided they meet both of the following: * The occupancy is not intended to serve ambulatory health care occupants for treatment or customary access. * They are separated from the ambulatory health care occupancy by a 1 hour fire resistance rating. Ambulatory health care facilities shall be separated from other tenants and occupancies and shall meet all of the following: * Walls have not less than 1 hour fire resistance rating and extend from floor slab to roof slab. * Doors are constructed of not less than 1-3/4 inches thick, solid-bonded wood core or equivalent and is equipped with positive latches. * Doors are self-closing and are kept in the closed position, except when in use. * Windows in the barriers are of fixed fire window assemblies per 8.3. Per regulation, ASCs are classified as Ambulatory Health Care Occupancies, regardless of the number of patients served. 20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR 416.44 This STANDARD is not met as evidenced by: Based on observation and interview Hafa Adai Specialty Group is not maintaining the required separation between its business occupancy and its ambulatory health care occupancy. Failure to maintain the required separation exposes staff and patients, who could be under general anesthesia, to increased risk from fire in the business occupancy portion of the facility. Findings include: On February 8, 2019 at approximately 2PM the space above the suspended ceiling in the recovery room area was observed. The CMS Health Surveyor and the maintenance employee were present. It was found that a barrier extended from the floor slab to the second story slab around the operating room. No such barrier was observed separating the recovery room from the hallway leading to the patient examination rooms. Also observed was the space above the suspended ceiling next to the door between the waiting area and the hallway leading to the patient examination rooms. No such barrier was in place to separate these two areas. The maintenance employee was familiar with this configuration and agreed with the observation.
K0211	Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full instant use in case of emergency, unless modified by 20/21.2.2 through 20/21.2.11. 20.2.1, 21.2.1, 7.1.10.1 This STANDARD is not met as evidenced by: Based on observation and interview the facility failed to maintain a means of egress free of all obstructions or impediments. Failure to do so could delay or prevent the prompt evacuation of staff. Findings include: 1. On January 31, 2019, between 1030AM and 1215PM, during a walk-through of the facility with the facility's maintenance employee the approximately 12 foot corridor between the bathroom and the billing office was observed to being used as a storage area for office documents and empty cardboard boxes. These were stored on a cart against one wall and reached a height of approximately 6 feet. This reduced the corridor width to approximatley 22 inches. The maintenance employee confirmed that the corridor was obstructed. This could affect all of the facility's staff. 2. On January 31, 2019, between 1030AM and 1215PM, during a walk-through of the facility with the facility's maintenance employee it was observed that the exit discharge located in the employee lounge area was obstructed by electronic devices The maintenance employee said the eelectronic devices had been placed at this location for eventual disposal. This could affect all of the facility's patients and staff.
K0223	Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors required to be self-closing are permitted to be held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment, entire facility, and all stair enclosure doors upon activation of: * Required manual fire alarm system, and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power 20.2.2.4, 20.2.2.5, 21.2.2.4, 21.2.2.5 This STANDARD is not met as evidenced by: Based on observation and interview the facility did not ensure that a door to a hazardous area, required to be self-closing, was being held open only by an automatic release device. Without an automatic release device there is no assurance that a door being otherwise held open, will close upon activation of a manual fire, smoke detectors, sprinkler system or loss of power. This could allow smoke or fire to spread rapidly and would affect all patients and staff. The facility also failed to ensure that hazardous areas were equipped with self closing doors, as required. This could allow smoke and fire to spread rapidly and would affect all patients and staff. Findings include: 1. On January 31, 2019 during a walk-through of the facility with the facility's maintenance employee the door between the nurse's station and the record room was observed to be equipped with a self-closure but was held open by friction on the latch surface while pressed against a bookshelf. The room was observed to contain combustible patient records on at least 20 shelves approximately five feet long. The room's dimensions are approximately 10ft by 10ft. The maintenance employee affirmed that the door was being held open by being pressed against a bookshelf and was equipped with a self-closing device. 2. On January 31, 2019 during a walk-through, with the maintenance employee, of the laundry and medical supply storage area adjacent to the operating room it was observed that within the following rooms (approximately 13ft x 7ft) were stored combustible medical supplies. None of these hazardous areas had doors equipped with self-closing devices. * The room containing a clothes washer and dryer. In this room was observed to be two automatic sprinkler heads. * The room directly opposite the room containing a clothes washer and dryer. This room did not have automatic sprinkler heads. * The room diagonal to the room containing a clothes washer and dryer. This room did not have automatic sprinkler heads. The maintenance employee acknowledged that these rooms did not have doors that were equipped with closures.
K0321	Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas must meet one of the following: Contain 1 hour rated enclosure when non-sprinklered Sprinkler protected with smoke resistive separation *Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors 20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7 This STANDARD is not met as evidenced by: Based on observation and interview the facility failed to provide protection from areas in which combustible materials were being stored. Failure to do so could result in a fire spreading with more speed and intensity reducing the time required for safe evacuation of personnel and patients. This could affect personnel and patients in the operating room and the recovery room. The patients could potentially be under the effects of general anesthetics. Findings include: On February 1, 2019 during a walk-through of the facility, with the CMS Health Surveyor and the Operating Room Technician it was observed that in the laundry room a penetration in the wall, behind the washer and dryer, approximately 12in. by 12in. had been cut to allow hot and cold water pipe to be run into the room. The penetration had not be sealed. This room was also being used to store combustible medical supplies. The room was approximately 13ft by 7 ft. The CMS Health Surveyor confirmed the observation. Also observed, in the same room, was an approximatley 12in. by 12in. penetration in the overhead located in the proximity of the washer and dryer. This penetration had not been sealed. The CMS Health Surveyor confirmed the observation.
K0342	Fire Alarm System - Initiation CFR(s): NFPA 101 Fire Alarm - Initiation Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit and 200 feet travel distance is not exceeded. 20.3.4.2, 21.3.4.2, 9.6.2 This STANDARD is not met as evidenced by: Based on observation and interview the facility failed to ensure that a manual fire alarm box was accessible, unobstructed and visible. Failure to do so could result in a delay to alert occupants of the building and fire fighters that a fire has started. This could affect employees and patients in the operating room and in the adjacent recovery room who could be under the effects of general anesthesia. Findings include: On January 31, 2019 during a walk-through of the operating room area with the CMS Health Surveyor and the facility's Operating Room Technician a manual fire alarm box was observed to be blocked by a wheeled cart upon which medical devices rested, a one foot high stool and a shelf assembly approximately six feet tall and four feet wide upon which medical equipment were stored. Both the CMS Health Surveyor and the Operating Room Technician observed that the manual fire alarm box was blocked as described.
K0345	Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm Systems - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This STANDARD is not met as evidenced by: Based on an interview with the office manager the facility has failed to maintain and test the facility's fire alarm control system as required. This could lead to a failure of the fire alarm control system which would prevent it from working as intended. This could expose staff and patients, potentially under general anesthesia, to an increased risk of injury or death due to a fire. Findings include: On February 1, 2019 at approximately 2PM, while performing record review the office manager was asked to provide records showing that the fire alarm control system had been maintained and tested on a semi-annual and annual basis. The office manager asked for examples of the testing and maintenance requirements. The following are those presented as examples: * Sealed lead acid batteries are required to be inspected and tested every six months. * The battery charger is tested annually. * The batteries undergo an annual 30 minute discharge test. These and other requirements are listed in Ch. 14, NFPA 72, Fire Alarm and Signaling Code 2010 Edition. The office manager said none of the inspections and tests listed as examples had been performed and that he had no records to show that they had been done.
K0353	Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This STANDARD is not met as evidenced by: Based on interview and record review the facility has failed to inspect, maintain and test the automatic sprinkler system on a monthly, quarterly, semi-annual and annual interval, as required. Failure to perform these required operations could result in the failure of the sprinkler system to function as intended. This could cause a fire to spread more quickly and with greater intensity resulting in injury or death. Findings include: On January 31, 2019 at approximately 2PM the office manager was asked to provide records of any sprinkler inspection, maintenance and testing records performed within the past year. The office manager provided an invoice dated December 7, 2018 for services performed by a company which declared on the document that the inspection of the facility's standpipe system was performed according to the National Fire Protection Association (NFPA) Standard 14, "Standard for the Installation of Standpipe and Hose Systems". The office manager was informed that CMS required that inspection, maintenance and testing on sprinkler systems were to be performed according to NFPA 25, "Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems" and that these were required to be performed on monthly, quarterly, semi-annual, annual and 5 years intervals. The office manager said he was not aware of this requirement. The office manager was asked if the facility if any other services were performed on the facility's sprinkler system. The office manager said that no other services were performed and that he had no other sprinkler system records for the year 2018.
K0355	Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 20.3.5.3, 21.3.5.3, 9.7.4.1, NFPA 10 This STANDARD is not met as evidenced by: Based on observation and interview the facility failed to store a fire extinguisher as required. Storing a fire extinguisher as required will ensure that it is available, accessible and will function as intended in the event of a fire. Findings include: On February 1, 2019 during a walk-through of the operating room area with the CMS Health Surveyor and the facility's Operating Room Technician it was observed that a fire extinguisher in the operating room was stored directly on the floor near the entrance to the operating room. Both the CMS Health Surveyor and the Operating Room Technician observed the fire extinguisher being stored directly on the floor.
K0712	Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 21.7.1.4 through 21.7.1.7 This STANDARD is not met as evidenced by: Based on interview and document review the facility failed to conduct fire drills on a quarterly basis as required. Failure to conduct fire drills as required, could result in the failure of the staff to respond quickly and efficiently in the event of a fire. Findings include: On January 31, 2019, at approximately 2PM the office manager was asked to provide records of fire drills held during 2018. Review of these documents showed that the facility held fire drills on October 18, 2018 and February 12, 2018. No fire drills were conducted during the second quarter of 2018 (April-June) and the third quarter in 2018 (July-September). The office manager confirmed that the only fire drills conducted in 2018 were held in February and October. This could affect all staff and patients.
K0751	Draperies, Curtains, and Loosely Hanging Fabrics CFR(s): NFPA 101 Draperies, Curtains, and Loosely Hanging Fabrics Draperies, curtains including cubicle curtains and loosely hanging fabric or films shall be in accordance with 10.3.1. Excluding curtains and draperies: at showers and baths; on windows in patient sleeping room located in sprinklered compartments; and in non-patient sleeping rooms in sprinklered compartments where individual drapery or curtain panels do not exceed 48 square feet or total area does not exceed 20 percent of the wall. 20.7.5.1 through 20.7.5.3, 21.7.5.1 through 21.7.5.3 This STANDARD is not met as evidenced by: Based on observation and interview the facility failed to ensure that loosely hanging furnishings met flame propagation criteria as required. Loosely hanging furnishings that do not meet these criteria could cause a fire to spread more quickly and with greater intensity than a loosely hanging furnishing that does meet flame propagation criteria. Findings include: On January 31, 2019, between 1030Am and 1215PM, during a walk-through of the facility with the facility's maintenance employee a cloth furnishing was observed to be tacked to the wall in the billing office. The furnishing was approximately 6ft by 4ft and was attached to the wall using push pins. The employee whose work station was positioned adjacent to the loosely hanging furnishing said that she brought the cloth from home. No markings or tags on the cloth were observed that would indicate that the cloth met the appropriate flame propagation criteria.
K0914	Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For, LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This STANDARD is not met as evidenced by: Based on an interview the facility has failed to test, on an annual basis, receptacles at patient bed locations or in locations where general anesthesia is administered. Failure to do so could increase the risk of medical equipment failing to operate as intended during surgery. This could cause injury or death. Findings include: On February 8, 2019 while requesting records related to receptacle testing the office manager and the maintenance employee said that no such testing had been performed in the operating room or the recovery room. This could affect all patients.
K0920	Electrical Equipment – Power Cords and Extension Cords CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This STANDARD is not met as evidenced by: Based on observation the facility was using two extension cords as a substitute for fixed wiring. This could cause an increased risk for fire due to the possibility that a high draw electrical device could be plugged into the extension cord and thus overloading it. This could cause injury or death to patients and staff. The facility also used power strips without considering general precautions. This could increase the risk of fire due to the possibility of overloading the power strip. This could cause injury or death to patients and staff. Findings include: 1. On January 31, 2019, during a walk-through of the facility with the maintenance employee and the CMS Health Surveyor it was observed that two extension cords had been dropped from the space above the suspended ceiling in the recovery room. One was plugged into a power strip and the other was plugged into a reclining bed. The CMS Surveyor confirmed the observation. 2. On January 31, 2019, during a walk-through of the operating room with the CMS Health Surveyor and the Operating Room Technician it was observed that a medical suction machine was plugged into power strip 1. Also plugged into power strip 1 was power strip 2. Power strip 2 was mounted on a movable cart assembly onto which were mounted several medical devices. The CMS Health Surveyor confirmed the observation.
K0929	Gas Equipment – Precautions for Handling Oxygen CFR(s): NFPA 101 Gas Equipment - Precautions for Handling Oxygen Cylinders and Manifolds Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99). 11.6.2 (NFPA 99) This STANDARD is not met as evidenced by: Based on observation and interview the facility has failed to store oxygen cylinders, as required. Failure to oxygen cylinders as required could increase the risk of injury or death. Findings: On February 1, 2019, during a walk-through of the facility with the CMS Health Surveyor and the Operating Room Technician two H oxygen cylinders (249 ft3) and one E oxygen cylinder (24.9ft3) were observed in a room with a sign on the door labeled "Guam Radiology Consultants". The cylinders were observed to be freestanding. At the time of the observation the Operating Room Technician was present to confirm the observation.