Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
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)
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.