| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 01C0001010 | (X3) Date Survey Completed 09/19/2019 |
| Name of Provider or Supplier The Southern Alabama Surgery Center, Llc | Street Address, City, State 2800 Ross Clark Circle, Suite 3, Dothan, AL | |
| 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) |
| 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 review of the Emergency Preparedness (EP) Program manual and interviews with the staff, it was determined the facility failed to ensure a volunteer policy was initiated for the EP Program which complied with State and Federal requirements. Findings include: Review of the EP Program conducted on 9/18/19 revealed no documentation of a policy for the use of volunteers during an emergency. An interview was conducted on 9/18/19 at 12:30 PM with EI # 2, Administrator, who confirmed the above mentioned findings. |