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)
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.