| 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) |
| 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 Lack of an annual review and update of the emergency preparedness plan could result in obsolete or outdated information and procedures which could compromise the safety of all patients and staff.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. |